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About Smoke signals. (Grand Ronde, Or.) 19??-current | View Entire Issue (Nov. 1, 2010)
Smoke Signals 9 NOVEMBER 1, 2010 r n Please circle the family size and annual household income that represents your family the closest in that line. family Sue ' ANNUAL HOUSEHOLD INCOME 1 $10,830.001 $12,996.001 $14,403.90 I S14.620 S0 $16,24S.00 $13,9S2 S0 $20,035.S0l $21,660 OOl OVER 2 $14,570.00 $17,484.00 $19,378.10 $19,669.50 $2US$iX) $25,49750 $26,9S4.SO $29,140.00 OVER 3 $18,310.00 $21,972.00 $24,35230 $24,71850 $27,465.00 $32,04250 $3373.50 $36,620.00 OVER 4 $22,050.00 $26,460.00 $2932650 $29,76750 $33,075.00 $3858750 $40,79250 $44,100.00 OVER 5 $25,790.00 $30,948.00 $34,300.70 $34,81650 $38,685.00 $45,13250 $47,71150 $51580.00 OVER 6 $29530.00 $35,436.00 $39,274.90 $39,86550 $44,295.00 $51,67750 $54,63050 $59,060.00 OVER 7 $33,270.00 $39,924.00 $44,249.10 $44,91450 $49,905.00 $58,22250 $61,54950 $66540.00 OVER 8 $37,010.0ol $44,412.0o $49j233o $49,350 $5S515.0o $64,76750 $68,46850 $74,020.00 OVER Please List All Tribally enrolled dependents In your household: Last Name: Age: Tribal Roll : Enrolled on Skookum Health Plan: Yes Any other insurance? , First name: No: ' Last Name: Age: Tribal Roll : Enrolled on Skookum Health Plan: Yes Any other insurance? First name: No: Last Name: Age: Tribal Roll : Enrolled on Skookum Health Plan: Yes Any other insurance? First name: No: "imimimn Please add a separate sheet of paper if you have additional dependents. PLEASE NOTE Please fill out and return only 1 survey per household (unless there is more than 1 family in your home). Please call one of the numbers below for additional surveys if needed. For questions regarding this survey, please contact Barbara Steere at 503-879-2487 Or Melody Baker at 503-879-2011. Toll free is 1-800-775-0095. Other ways to do the survey: Tribal Web site www.grandronde.org Fax: 503-879-1547 Barbara Steere, Health Plan Specialist Phone-in to do the survey with one of the following: Teri Mericer: 503-879-2008 Melody Smith: 503-879-2011 Barbara Steere: 503-879-2487 Address to mail back to CTGR - Health Plan 9615 Grand Ronde Road Grand Ronde, OR 97347
