Siletz news letter., April 01, 1990, Page 7, Image 7

JSILETZ, OREGON
April 1990 -
USDA NEWS
DEATH BENEFIT BENEFICIARY DESIGNATION FORM
Submitted by: Sylvia Brock
The USDA Food D istribution fo r
S a le m w ill be April 9, 10, and 11, 1990
from 8:00 a.m . to 12:00 noon and from
1:00 p.m. to 4:30 p.m. in Salem to the last
ap p o in tm e n t.
T he S ile tz USDA Food
d istrib u tio n in A p ril w ill be the 11th,
12th, and 13th, 1990. Sharon will be in
Salem and I will be open in Siletz. We need
time to complete our paper work, so if you
c o u ld
h e lp
us
by
k e e p in g
your
appointments, then we could have the extra
time to w ork on our Adm inistrative duties
to provide you a better service.
I
_________ a_______________________________________________Hereby
(Please Print Full Name)
1st
B eneficiary:
SKILLET BEEF AND MACARONI:
1 Can of beef
1/4 chopped onion
1 can tomato sauce
1 can whole kernel corn, drained
1 cup cooked macaroni
2 teaspoon chili powder
_________________________________________
(Please print full name)
Beneficiary’s current address
City
This facility is operated in accordance with
U.3. Department of Agriculture Policy, which
prohibits discrimination on the basis of race,
color, sex, age, handicap, religion, or national
origin. Any person who believes he or she has
been discriminated against in any USDA-related
activity should write to:
ADMINISTRATOR
Food & Nutrition Service
3101 Park Center Drive
Alexandria, VA 22302
Zip Code
(____ )_________________________
v as my beneficiary for the $5,000 death benefit insurance.
_________ :___________________/
_______________________ _______
,
Parent signature if minor
Social Security No;______________________
Date of B irth __________________
Roll. No.____________________
D a te ______________
Return completed form to:
Confederated Tribes of Siletz
D.B. Insurance
P.O. Box 549
Siletz, OR 97380
[ ] CHECK HERE IF THIS IS A CHANGE IN BENEFICIARY OR BENEFICIARY ADDRESS:
(OPTIONAL)
2nd B eneficiary:
_________ _____________________ _____________________
(Please print name)
________________________________
( _ _ ) ___________________
Current address
3rd
B eneficiary:
Phone No.
____________________________________________________
(please print name)
_______ I________________________________ (_____) _ ^ ______________________
Current address
. Phone No.
1/2 teaspoon seasoned salt
1/2 cup shredded cheese
C ook beef and onion in a sk ille t until
sauteed, (fully heated) drain well. Stir in
next five ingredients.
S im m er, stirring
occa sio na lly, 5 or 10. m inutes or until
thoroughly heated. Stir in cheese. Makes 4
to 6 servings.
State
Beneficiary's telephone number
Signature
ASKED TO BRING IN DOCUMENTATION TO
UPDATE YOUR FILE AND YOU DO NOT BRING
IT IN, YOU WILL BE REFUSED FOOD UNTIL
YOUR FILE IS UP TO DATE.
We are looking for a new warehouse
site in the Salem area. We will keep you
posted as to any change of address.
IF YOU INTEND TO CLOSE YOUR FILE
BECAUSE OF OVER INCOME OR GOING TO
FOOD STAMPS, PLEASE WRITE OR CALL SO
THAT WE MAY PROPERLY CLOSE YOUR FILE.
designate
TRIBAL
CHANGE FORM
NAME:
________________________ ______________ ___ _____
ROLL NO.: _____
DATE OF BIRTH:
J__________
(Maiden)
S o c ia l S e c u r ity No.
PLEASE CHANGE YOUR RECORDS TO SHOW THE FOLLOWING:
Change o f A ddress
From:
.Î
To:
E f f e c tiv e D ate:
Change o f Name
From:
To:
E ff e c tiv e D ate:
Reason f o r change:
___ M arriage ;
Co u r t o r d e r ___ O th er
;. ; I
Copy a tta c h e d
I f Court o r d e r , p le a s e s p e c if y below ;
S ig n a tu re
—j-3--------------:--------- ;____________ _
Address
i
---------------------------------------- ---------
Date-
------
Send to : C o n fed erated T rib e s o f S i l e t z
E n ro llm en t D ept.
P.Ó, Box 549 - ,
1
S i l e t z , OR 97380
PAGE 7