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Smoke Signals 15
DECEMBER 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 $14,620.501 $16,245 00 $18,952301 $20,035.501 $21,660.00 1 OVER
2 $14370.00 $17,484.00 $19378.10 $19,66950 $21,855.00 $25,49730 $26,95430 $29,140.00 OVER
3 $18,310.00 $21,972.00 $24,352.30 $24,71830 $27,465.00 $32,04230 $33,87330 $36,620.00 OVER
4 $22,050.00 $26,460.00 $2932630 $29,76730 $33,075.00 $3838730 $40,79230 $44,100.00 OVER
5 $25,790.00 $30,948.00 $34,300.70 $34,81630 $38,685.00 $45,13230 $47,71130 $51,580.00 OVER
6 $29,530.00 $35,436.00 $39,274.90 $39,86530 $44,295.00 $51,67730 $54,63030 $59,060.00 OVER
7 $33,270.00 $39,924.00 $44,249.10 $44,91430 $49,905.00 $58,222.50 $61,54930 $66,540.00 OVER
8 $37,010.00 $44,412.00 $49,223.30 $49,9633o $55315.0o $64,76730 $68,46830 $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:
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Last Name:
Age:
Tribal Roll :
Enrolled on Skookum Health Plan: Yes
Any other insurance?
First name:
No:
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