Smoke Signals 9
NOVEMBER 15, 2010
Please circle the family size and annual household income that represents your family the closest In that line.
Family Size ANNUAL HOUSEHOLD INCOME
1 $10,830.001 $12,996.001 $14,403.90 I $14,620.50- $16,24S.OO $18,952.501 $2O,O3$.50 $21,660.00 OVER
2 $14,570.00 $17,484.00 $19,378.10 $19,66950 $21,855.00 $25,49730 $26,95450 $29,140.00 OVER
3 $18,310.00 $21,972.00 $24,35230 $24,718.50 $27,465.00 $32,042.50 $33,873.50 $36,620.00 OVER
4 $22,050.00 $26,460.00 $29,326.50 $29,76730 $33,075.00 $38,58750 $40,79230 $44,100.00 OVER
5 $25,790.00 $30,948.00 $34,300.70 $34,816.50 $38,685.00 $45,132.50 $47,711.50 $51,580.00 OVER
6 $29330.00 $35,436.00 $39,274.90 $39,86530 $44,295.00 $51,677.50 $54,63030 $59,060.00 OVER
7 $33,270.00 $39,924.00 $44,249.10 $44,91450 $49,905.00 $58,22250 $61,54930 $66,540.00 OVER
8 $37,010.001 $44,412.0o $49,223.3o $49,96330 $5S31S.0O $64,76750 $68,468.5o $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:
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Last Name:
Age: Tribal Roll :
Enrolled on Skookum Health Plan: Yes
Any other insurance?
First name:
No:
Last Name: ; First name:
Age: Tribal Roll :
Enrolled on Skookum Health Plan: Yes No:
Any other insurance?
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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 Baker: 503-879-2011
Barbara Steere: 503-879-2487
Address to mail back to
CTGR - Health Plan
9615 Grand Ronde Road
Grand Ronde, OR 97347