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Get KS Per Capita Payment Options Form - Prairie Band Potawatomi Nation

East 14 days before Per Capita Distribution Date NAME: _______________________________________ ROLL # _______________________________ ADDRESS: ___________________________________________________________________________ CITY / STATE / ZIP: ___________________________________________________________________ PHONE NUMBER (H): ______________________________ (C): _____________________________ I HAVE SELECTED THE FOLLOWING PAYMENT OPTION FOR MY QUARTERLY PER CAPITA PAYMENT AND UNDERSTAND THAT I MUS.

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