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About Smoke signals. (Grand Ronde, Or.) 19??-current | View Entire Issue (Dec. 1, 2010)
Smoke Signals 15 DECEMBER 1,2010 Please circle the family size and annual household Income that represents your family the closest in that line. Family Size ANNUAL HOUSEHOLD INCOME 1 $10,830.00 $12,996.001 $14,403.90 I S14.620S0 $16,245.001 $18,9S2.S0 $20.03550 $21,660.00 OVER 2 $14,570.00 $17,484.00 $19,378.10 $19,669.50 $21,855.00 $25,497.50 $26,954.50 $29,140.00 OVER 3 $18,310.00 $21,972.00 $24,352.30 $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 $29,530.00 $35,436.00 $39,274.90 $39,865.50 $44,295.00 $51,67750 $54,630.50 $59,060.00 OVER 7 $33,270.00 $39,924.00 $44,249.10 $44,91450 $49,905.00 $58,22250 $61,549.50 $66,540.00 OVER 8 $37,010.00 $44,412.00 $49,223.30 $49,963.5o $55,515.00 $64,76750 $68,468.50 $74,020.0o OVeT Please List All Tribally enrolled dependents in your household: Last Name: First name: ' Age: Tribal Roll : Enrolled on Skookum Health Plan: Yes No: Any other insurance? Last Name: First name: Age: Tribal Roll : Enrolled on Skookum Health Plan: Yes No: Any other insurance? 1 1 1 1 "" 1 Last Name: First name: . Age: Tribal Roll : Enrolled on Skookum Health Plan: Yes No: Any other insurance? . 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. I 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
