Per-Capita Tax Withholding Form

All changes must be in by the 3rd Friday of the month.

If you encounter issues submitting this application through your mobile browser, download the SmartSheet app (it's free) or use a desktop or laptop computer. https://apps.apple.com/us/app/smartsheet-teams-projects/id568421135 https://play.google.com/store/apps/details?id=com.smartsheet.android&hl=en_US&gl=US If you want a copy of your submission, remember to check the box at the end of the form.

Last Name:*

First Name:*

Middle Initial:

Suffix:

Date of Birth:*

Social Security Number:*

Phone Number:*

Email Address:*

Please choose one of the following:*

20% -- $1,600.00

27% -- $1,460.00

Proof of Identification*

Please upload an up-to-date Tribal ID card or Government Issued ID.

Drag and drop files here or

Applicant Digital Signature:*

By my signature below, I declare that all of the above statements are true and accurate. Withholding information, false information/altered documents will result in immediate denial.

Today's Date:*

Send me a copy of my responses

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