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Name: Social Security # (last four digits): / / Date of Birth: Tribal Identification # : Alt. Contact #: Email Address: I certify that I reside on a Federally recognized Tribal land. (For Tribal Residents Only) PLEASE READ AND ACKNOWLEDGE YOU AGREE BY INITIALING EACH STATEMENT BELOW, UNDER PENALTY OF PERJURY The information contained within this application is true and correct. I acknowledge that providing false or fraudulent documentation in order to demonstrate eli.
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