) Prairie Band Potawatomi Nation

A Per Capita Office - Loans

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***** * ****, *******, ** 66509

Phone 785-***-**** - Fax 785-***-****

Per Capita Advance Application Form

Tribal Member Name: Date:

Enrollment #:2862U_. SSN: XXX-XX- DOB: / /

Direct Phone #: Email:

Loan Amount Requested: $1,000.00 (no exceptions) *$25 Fee will be added, see policy for details*

Repayment Schedule: 3 sequential quarterly payments withheld from Per Capita:

1" sequential quarterly payment: $342;

2™ sequential quarterly payment: $342; and

3 sequential quarterly payment: $341.

Certification: ! hereby acknowledge receipt of the Per Capita Advance Policy and agree to its terms. 1

understand that the Per Capita Advance will be paid to me in the same manner that the quarterly Per

Capita Distributions are.

I give permission to the Finance Department to verify the information on this application and

understand that any false information or dishonesty in the making of this application may result in

ineligibility to receive a Per Capita Advance from this application or future applications.

In consideration of a Per Capita Advance to me by the Nation, hereby irrevocable pledge and assign

that portion of my Per Capita necessary to satisfy any outstanding balance of the Advance in the

amounts of the scheduled repayments and that such irrevocable assignment shall not constitute a

claim on the Per Capita but is a Voluntary Pledge and Assignment. understand that cannot revoke

this pledge and assignment and that the Per Capita Advance repayment will be garnished from my Per

Capita according to schedule or as otherwise agreed until the Advance is paid in full. Once the Per

Capita Advance is paid in full, this assignment and pledge shalll become permanently null and void.

Tribal Member Signature Date

**Application Must Be Notarized and Submitted with Photo ID to the Per Capita Office for Processing**

Notary Acknowledgment

In the State of. in the County of.

on this (Date), the above person personally

appeared and signed the foregoing instrument before me.

Notary Public Printed Name:

Notary Public Signature:

‘As Amended and Approved on 10/7/2020

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