U
pdated/Approved 2/17/16
Soboba Band of Luiseño Indians
P.O. Box 487, San Jacinto, CA 92581 * 951.654.2765
PER CAPITA DEDUCTION AUTHORIZATION
IMPORTANT: This form must be completed with correct and verifiable information.
Please note only the following will be honored: Federal Tax Liens- Voluntary Child Support-
Tribal Credit Loans- Tribal Housing Loans- Federal Student Loans-AMIHA- Restitution
TRIBAL MEMBER INFORMATION
Bank Name:
Account/Loan #:
Routing #:
Amount to be withheld: (Raise or Lower)
$________________________
Continue deduction until cancelled
End deduction on this date _________________________
Payable To: Additional Comments:
Name ________________________________________
Address ________________________________________
________________________________________
________________________________________
Yes
No
If “Yes” enter Amount: $___________________
Follow District Attorney’s Wage Garnishing
Order? Yes No
Name ________________________________________
Address ________________________________________
________________________________________
________________________________________
I hereby authorize Soboba Band of Luiseño Indians (hereinafter “Company”) to withhold monies for payment
from my Per Capita in the amount specified above. This authorization is to remain in full force until Company
has received written notice from me of its termination in such time and in such manner to afford Company
reasonable opportunity to act on it. IMPORTANT: Completed form must be received by the 15
th
of the month.
I understand there will be a $25 service charge each month.
___________________________________________________ _____________________________
Signature Date
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signature
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