NOTICE OF DISTRIBUTION Mississippi Band of Choctaw Indians

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					                     NOTICE
                       OF
                  DISTRIBUTION
           Mississippi Band of Choctaw Indians


                   Silver Star Convention Center
                        December 4 th, 2012
                          9:00am - 6:00pm




Adopted by Resolution CRO 12-123 on September 26 t \ 2012
                                  IMPORTANT NOTES

1. The Tribal Council of the Mississippi Band of Choctaw Indians ("MBCI" or "Tribe")
   passed a resolution which allows each enrolled member of the MBCI to be eligible to
   receive a payment of $500.00 for the December 2012 distribution. The Tribe will issue a
   separate payment for each enrolled member, regardless of age.

2. The Mississippi Band of Choctaw Indians is not requiring anyone to accept this payment,
   nor is the Tribe entering into a contract to make the payment or guarantee the payment.

3. It is the intention of the Tribal Council that payments for minor children and dependents
   be spent on them, or the family as a whole, and that their needs not be neglected.

4. Individuals wishing to have income tax taken out of their payment mnst fill out a
   Voluntary Withholding Form (Form W-4V) and return to the Office of Tribal
   Distribution no later than November 1st, 2012 at 4:30pm. This form is attached.

5. The IRS considers per capita payment distribution or in-kind goods or services received
   in lien of a distribntion payment to be personal income. Recipients should remember to
   report these payments on their income tax return (Form 1040) when they file their income
   taxes for the calendar year in which they receive the payment. A 1099 Tax Form will be
   issued.

6. These payments may also affect the eligibility of persons and families for certain federal
   programs, including, bnt not limited to: food stamps; Supplemental Security income
   (SSI); General Assistance; Head Start; Women, Infant & Children (WIC); Low-Income
   Energy; among other programs. It is the recipient's responsibility to check with the
   administering agency of that program to see what effect the payment may have on
   eligibility or amounts of assistance.

7. If a distribution payment is returned or otherwise not claimed, it shall be retained by the
   issuer for six (6) months after the date it was originally mailed. After this date, it shall be
   turned over to the Secretary-Treasurer for disbursement into the general revenue fund of
   the Tribe.

8. In order for the Office of Tribal Distribution to authorize the re-issuance of a payment
   that was lost, stolen, or not received, a notarized affidavit must be completed and
   returned to the Distribution Manager within 30 calendar days of the distribution date. The
   affidavit may be picked up from the Office of Tribal Distribution or they may be mailed.




                                                                                                1
                          DETERMINATION OF ELIGIBILITY

NEW APPLICANTS
  • Only enrolled members of the Mississippi Band of Choctaw Indians are eligible to
     receive a distribution payment.
  o If an eligible non-enrolled member is enrolled in another tribe, a signed disenrollment
     action must be received by the Tribal Enrollment Office by November IS' at 4:30pm for
     the December distribution.
  • In order to receive a distribution payment, enrolled members of the Mississippi Band of
     Choctaw Indians must complete the Application for Tribal Distribution and turn in to the
     Tribal Enrollment Office by November 1st at 4:30pm for the December distribution.
  • The Application for Tribal Distribution must be completed in its entirety. Any incomplete
     sections may cause a delay in receipt of your distribution payment.
CHANGE OF STATUS
  • If an eligible member has previously received a distribution payment, they must complete
    a new Application for Tribal Distribution for any of the following changes in status:
        o Addition of new eligible dependent, either through adoption or birth
        o Member has now become 18 years of age
        o Change in custody
        o Name change
        o Address change
  • The original Application for Tribal Distribution must be received by the Tribal
    Enrollment Office, copies or faxes will not be accepted.
COURT ORDER
  • The deadline for Choctaw Legal Defense is October 25'\ 2012 at 12:00pm.
  • Any Order of the Tribal Court restraining the issuance or requiring a payment to re-issue
    to another party must be received by the Tribal Court Clerk's Office October 26'\ 2012
    at 12:00pm.
  • If the residence of the child(ren) has changed or the per capita payment agreement has
    changed since the July 2012 distribution, the individual receiving the payments on behalf
    of their child or dependent will need to provide a certified copy of the full court order
    stating such changes to the Tribal Enrollment Office by 4:30pm on November IS', 2012.
  • Custodial court orders must be received by the MBCI Tribal Enrollment Office by
    November IS' at 4:30pm for the December distribution.
NEWBORNS
  • Eligibility is restricted to persons being born before l2:00am December 4'h, 2012.
  • Parents of newborns have until 12:00pm December 31 s', 2012 to submit an Enrollment
    Application and an Application for Tribal Distribution to the Tribal Enrollment Office.
  • Accommodations may be made for the acquisition of birth certificates and Social
    Security cards after the Tribal Enrollment Office has received the completed Enrollment
    Application and the Application for Tribal Distribution but cannot exceed 6 months past
    the date of distribution as stated in Tribal Code XV Chapter 4 Section 15-4-1.




                                                                                           2
18 YEARS OF AGE
   • Those enrolled members of the Tribe who reach their IS th birthday on or before
      December 4"1, 2012 must submit a new Application for Tribal Distribution if they want
      to pick IIp their distribution payment withont their parent or guardian present.
   • Applications must be submitted by November 1st at 4:30pm for the December
      Distribution.
MILITARY/INSTITUTIONALIZED
  • Tribal members serving in the military or otherwise institutionalized outside the
     reservation have until 4:30pm on December 31 st, 2012 to file an Application for Tribal
     Distribution.
VESTING OF RIGHTS TO DISTRIBUTION
  • An individual's right to distribution shall vest at 12:00am on December 4th, 2012.
     Unless an individual is alive at the time distribution vests, he/she and his/her heirs shall
     not be entitled to the distribution.
APPEALS
  • In the event that a person wants to appeal not receiving a distribution payment, or ifthere
     are eligibility questions, they must submit a letter of appeal to the Tribal Distribution
     Appeal Panel Chairperson Linda Williams
  • If a claimed child or dependent has lived in a household for more than 90 calendar days
     and the parent, guardian or custodian does not live in that household, the Tribe reserves
     the right to issue the check to the child or dependent and to the head of household in
     which the child now resides. Individuals must submit a letter of appeal to Linda
     Williams, Chairperson.
  • The Tribal Distribution Appeal Panel consists of Linda Williams, Mae Bell, and Gilbert
     Thompson
                                    PAYMENT PROCESS
       **THE TRIBE WILL NOT GIVE CHECKS TO 3RD PARTIES**
INDIVIDUALS
In Person/Paper Check
    • Individuals wanting to pick np their payment in person may do so by reporting to the
       Silver Star Convention Center on December 4th, 2012 between 9:00am-6:00pm.
    • Individuals mnst bring at least one (1) form of valid government issued identification in
       order to pick np their payment. Valid identification examples include a driver's license,
       state issued identification, passport, tribal identification card, Social Security card,
       printout from Social Security Administration or Choctaw Health Center face sheet that
       includes the individual's roll number or Social Security number. Copies of Social
       Security Cards will NOT be accepted
Direct Deposit
   • Individuals wanting to use direct deposit mnst use the Direct Deposit Anthorization
       Form, which is attached. The original form must be completed, notarized and sent to the
       Office of Tribal Distribution. You must make a copy if you would like to keep it for your
       records.

                                                                                                3
   •   This form must be filled out completely, notarized and returned to the Office of Tribal
       Distribution, c/o Distribution Manager by November 1st at 4:30pm for the December
       distribution.
   •   Eligible members may use the same form to have their dependent's or minor children's
       check put into the same account, granted that the necessary documents are provided prior
       to authorization.
DEPENDANTS
  • Individuals wanting to pick up their dependant's payment must present one (I) valid fmID
     of identification for each dependent, in addition to the parent/guardians valid
     identification.
MINORS
  • Individuals under 18 years of age with children are nevertheless still minors for the
     purposes of this distribution and payments will be made payable to both the minor and
     the parentiguardian.
  • Parents/guardians are required to present one (I) valid form of identification for each
     minor, in addition to the parent/guardians valid identification.
SOCIAL SERVICES
  • For children in foster care, their payment will be issued to Children & Family Services
     for the benefit of the child.
  • Payments shall be re-issued by Children & Family Services in a timely manner to the
     appropriate parent or guardian.

                                  CONTACT INFORMATION

   EMAIL: distribution@choctaw.org                    Choctaw Legal Defense
                                                      (601) 650-7449
   Barbara Farmer, Distribution Manager
   Office of Tribal Distribution                      Angela Stevens, Tribal Enrollment Officer
   P.O. Box 6090                                      Tribal Enrollment Office
   Choctaw, MS 39350                                  P.O. Box 6365
   Phone: (601) 650-1560                              Choctaw, MS 39350
   Fax: (601) 656-4839                                Phone: (601) 656-5251 ext.l504
   Email: bfarmer@choctaw.org                         Email: angela.stevens@choctaw.org

   Linda Williams, Chairperson
   Tribal Distribution Appeal Office
   P.O. Box 6010
   Choctaw, MS 39350
   Phone: (601) 650-1545
   Email: linda.williams@choctaw.org




                                                                                                  4
                                                                                                                                 llilCOIl1Et ~ P\Jb. 505 I[J find out if you shoold adius.1
Form W-4 (2012}                                                                                                                  'jOOfvffihh~        on FOO"n W-4 a W-4P.
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situaf-on changoo.                                                                                                               ,vbeo all allowarr....es rue chimed 00 too FD/TI'.I \'1- J
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and Ee,IITl1atOO TIU..                                                                                                           ~n&tructicm!Cf Noor~id8f11 NiE!N.,         OOlCfe
                                                                                                                                 «ffifl(;~jng   this form.
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ex~tion Imm withholding if ~ incorr>& excso:ds                                                                                   o&ffe.:l, I.i5E' Pi.J:I. 50S 10 see ho"N Iffi:, al'f"oCU"ll.l~ ~
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                                                                                                                                 future ooyelopmenbl. 100 IRS hils crsated II pag9
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                                                                 ma), tmEi acklitiooallu. If you hsve pl8naioo -oraooLlrty
                                                                                                                                 CJn that page.

                                                       Personal Allowances Wo rksh 99t (Keep for your records.)
A       ~l"It9f" ~1   ft   for yoursmf If 00 ooe 9159 can claim you as a depend9nt.                  •                                                                          A
                                  • You are single and havG only ooe Job; or                                                                                 }
B       EntGr "1- if:·[           • You aremarrloo, have only one job, and your spous.odoes not work: or                                                                        B
                         • VOUrW3~GS from a second Job or your spouse's wages (orthll talal of both) am $1 ,.500 or 1005.
c       Enw ~1" for your spouso. But, you may chQ()SG to enter "-0·" If you are marrklod and have either a wooing spouse                                          Of   more
        than on9 jOb. (EntBring --0-" may OOIp you avoid having too IittlB tax. with~d.) ,           • ~ • •                                                                    c
o       Enter nurnb9r of d&>pendents «)thec ltIan your Sp:luse or yournelf) you "''ill dilim on your tax return .                                                               o
E       !;nter ~1 ~ Hyo.u win filQ ag hood of housohold on your tax r,gtum (900 concfrtioos undflf Hoad of nous9hold abovQ)                                                     E
F       !;I\u,r '"1 n ifyoo haw at Ioo.st $1.900 of .ehlld or-dop4ndont OIIro ox~nSQ.s for wl"llch you f)lan toclalm a CMdit                                                    F
        (N.ote. Do not Include child support payments. S9G PI.lb_ 503, Child and Dependent Caroe r;xpQl1soo. for ootails.)
G       Chikl Tax Credii Qncluding additional child tax credit). Sge Pub. 972, Child Tax Crooit, for more information.
        • If your total Jnc:ome will be less than $.61.000 ($90,000 if man100), !Qflter "'2"' for £oach ~gibi9 child; thoOO lass ~1H if you have three to
        seven eligible chik:lnm or lass '"2" if you have- 91ght or more eligible children .
        • If your total income will 00 tlEltweerl $61,000 and $84,000 ($90,000 and $119,000 if married), enter                 ~1·   for each &tigible child •                  G
H       Add [nes A throlgh G and sow total trere. (Note. This may b3 dHf9rent from the number of exemptions yoo elm on !foor lax retum.) ... H
                                    • If you plan to itmlizo Of claIm Bdjustmont9 10incorM and want to roouCQ your wlthl"lokjing, S-QQ IhG Doductions
        For accura.cy,                and MjuatrMnlsWorkslleet on page 2,
        complete all                • If you ale singla and have more than one Job or are married and you and your spouse both work and tho comblood
        worksheets                  earnings from 011 jobs exceed $40,000 ($10,001) if married), $6161 the TWo-Eamers/Multip(e Jobs Worksheet on pa.ge 2 to
        that apply.    {            avoid having too little tax withheld .
                                    • If neither of the above situations applies. stop here and enter Ihe nurnl:Jeor from ling H on Hf\19 5 of Fonn W-4 00I0w.

- ' - - - ' - - - 5&pDrata h@l"i and give Fonn W-410 your 9I11p1oYir. Keep thi top part for your rKOrds. - - - . _ . - - -

                                                Employee's Withholding Allowance Certificate
F~      W-4                                                                                                                                                            OMS No. 154S-0074

                                       ... WMthfryou.lra .ntilltd III claim a el!rtMn number of allowAnces or .InnnptiM from withholdinG is
                                                                                                                                      form t() the ms .




                                                                                                  • H )'owlilst name c:iffere from that
                                                                                                     check hue. You must
                                    aJlCM'ance3                       (from                                                                     page
    6     Additional alTOUflt, if any, you want v/ith:hQld from BaCh paychock
    1     I clalm axQmption from wrthholdlngfor 2012, and I cGrtify that I roM bo1h Of too follOWirsg condltioflsfor Q,xMlpUon .
          • last year I had a right to a refund of all federal income tax withheld becauSQ I had no tax I~bility, 8nd
          • Th~ year ~ expeocl a refund of all federal income tax withheld because I QXpect to haw no· tax ".::'i"':''i-----.lLCL
          If


Empl-oyea's signature
(This form is not yaljd unless you sign 11.) ..                                                                                                 Date.
   8     Employer's MITIS ard addre-ss (Employer: Completer fine& fI and 10 <:rij if sending to ~ IRS.}


J:or Privacy Act and PaPQlWorx R~duetion Act NoUea.!H paga 2.                                                          Cal. No. 1£12200                                    FOIm W-4 {2,"21




                                                                                                                                                                                             5
     New         _OVER 18 YEARS OLD                _CHANGE IN CUSTODY                  _NAME/ADDRESS CHANGE
                 (l.D. with birthday)                    (Copy of Court Order)

                                 Application for Tribal Distribution
This form should be completed by the Head ofhousehold OR whose name will appear with the under 18 years old
name on the check.

Head of Household (Applicant, if over the age of 18):

Name _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Marital Status,_ _ __

Date of Birth_ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Street Address or Box_ _ _ _ _ _ _ _ _ _ _ _ __

City_ _ _ _ _ _ _ _ _ _ _ _ _ _ State_ _ _ _ Zip Code _ _ _ __

Social Security Number_ _ _ _ _ _ _ _ _ Choctaw Roll Number_ _ __

Telephone-Work._ _ _ _ _ _ _ _ _ _ Telephone-Home_ _ _ _ _ _ __

Community (if applicable), _ _ _ _ _ _ _ _ _ _ _ _ _ __

Is the Head of Household a tribal member of the Mississippi Band of Choctaw Indians?
Yes              No_ _ _ __

Please list only the child or children that are pending for enrollment or who has been enrolled with the Mississippi
Band of Choctaw Indians and did not receive the July 2012 Tribal Distribution of Funds.

 Full Name        Choctaw Roll       Soc. Sec. Date of          Parent or         Relation to
                    Number          Number     Birth            Guardian          Head



2_ _ _ _1_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ , _ _ _ _ __

3_ _ _ _1_ _ _ _ _ - - - - - - - - - - - - - , - - - - - -



                                                        Signature of Head of Household

This form may be returned in person to the Tribal Enrollment Office at the Tribal Office Building or by mail to:

                                             Application for Tribal Funds
                                                   P.O. Box 6090
                                                Choctaw, MS 39350

New applicants (enrolled members who have not made prior application) living on or near the Choctaw Reservation
must complete this application and return the Application by 4:30pm, November 1", 2012, to receive a check on
December 4'" 2012.

The deadline for newborns to return the completed application is December 31",2012, at 12:00pm. Postmarked by
December 31", 2012.


                                                                                                                       6
                                                                                                                [   ~l<lpk \    (11 )1 I) check IlLTC




                                   DIRECT DEPOSIT AUTHORIZATION
Use this form to
    •    Estab lish New Direct Deposit Authorization at a Bank or Credit Union
    •    Change Financial Institution alld/or Accoullt Type or Number
Mail the ORIG INAL form to:
Distribution Manager
Office of Triba l Distribution
P.O. Box 6090
Choctaw, MS 39350
Instructions
     I. Comp lete all information listed below including name and account number at financial institution and
          whether deposit to a checking or savings account is requested
     2. For checking account-attach a voided personal check or letter from you financial institution on their
          letterhead which includes their routing number and your account number
     3. Savings account-attach a statement from your financial institution or letter from you financial institution on
          their letterhead which includes their routing number and your account number
     4.   Sign this form , notarize it and return to the Office of Tribal Distribution
Important Reminders:
     I.   Distribution funds are credited to your account on the day of distribution, as approved by the Tribal
          Council
     2.   Failure to notify the Office of Tribal Distribution in a timely manner of changed or closed accounts may
          substantially delay the receipt of payments if an attempt is made to deposit funds into a closed account.

o   Checking account: a voided check or letter from you financial institution on their letterhead which includes
their routing number and your account number is required to process this authorization

o Savings account: attach a statement from your financial institution or letter from you financial institution on
their letterhead which includes their routing number and your account number is required to process this
authorization




                       THOMAS B. A NDERSON                                                                             IO[)(
                       ttI.MY ANDERSO N
                       l 'U M I . i"lCQHlnl Rd.
                       II,-,ylcl .... " . US·" 123·1.5                                                  (Hl (



                                _A)A PLE
                       ~~~______S _______~ $I~__~
                         b:,
                                        _______________________                                                          ( ' Q.l~ l ~




                          Util Q~1 OAN" (H C~lll (H h "




                                        I                            I
                         1. ROl.1ling Nvm ~ '            :2 . A.(CQun t N um oo r   3. Cha-<:k NvmbGr




                                                                                                                                                        7
PRINT CLEARLY OR TYI'E- An) discrepancies may cause a delay in rccciying your payment
AUTHORIZATION: I authorize the Mississippi Band of Choctaw Indians and the financial institution listed below to
initiate electronic credit entries, and if necessary, debit entries and adjustment for any credit entries in error to my account
listed below. This authority will remain in effect until I have canceled it in writing to the Office of Tribal Distribution

oEstablish NEW account                  oChange existing account
                                                                                Signature
FINANCIAL INSTITUTION INFORMATION


Name of Financial Institution           City             State    Zip    ABA Routing #          Account #
              ***to locate your ABA Routing # and Account # use the SAMPLE on the previous page*--
APPLICANT INFORMATION                            Tribal Member? DYes                       oNo

First                 Middle                     Last                  Social Security #                Tribal Roll #


Street Address                          City               State                Zip                     Phone Number
DEPENDANT INFORMATION

First                 Middle                     Last                  Social Security #                Tribal Roll #


First                 Middle                     Last                  Social Security #                Tribal Roll #


First                 Middle                     Last                  Social Security #                Tribal Roll #

                                                    SWORN AFFIDAVIT
I,                                               , the undersigned, first having been duly sworn on oath state as follows:
        I.   I am an enrolled member of the Mississippi Band of Choctaw Indians (the "Tribe") and/or my dependents are
             enrolled members of the Mississippi Band of Choctaw Indians and as such, am/are eligible to receive distribution
             payments when authorized by the Tribal Council.
        2.   I make this affidavit that my distribution payment and/or my dependant's distribution payment shall be made
             electronically to the above named financial institution
        3.   I understand that making a false affidavit to receive a distribution payment is a crime and that I can be prosecuted
             in Tribal and/or Federal Courts for receiving a distribution payment under false pretenses.
        4.   I am under no legal disability which would prevent my making this affidavit and I have fully read and understand
             it.
Further, affiant sayeth not.
STATEOF _________________________
COUNTYOF _______________________
          Personally appeared before me, the undersigned authority in and for the jurisdiction aforesaid, the undersigned
-;:-__;--.,---:-_ _--:-:-_-;-_::::-,:-;--_ who after being by me first duly sworn on his/her oath that the matters and
facts in the above and foregoing affidavit are true and correct to the best of his/her knowledge and belief.


                                                                       NAME OF AFFIANT
Sworn to and subscribed before me this the ____ day of _ _ _ _ , 20 _ _.


                                                                       Notary Public
My Commission Expires:


                                                                                                                                8
                           Policy and Legislative Office

                IMPORTANT DISTRIBUTION DATES TO REMEMBER

October 25th at 12:00pm      Choctaw Legal Defense Deadline (601-650-7449)

October 26th at 12:00pm      Choctaw Tribal Court Deadline (601-650-1658)

November 1st at 4:30pm       Deadline for new applicants to turn in an Application for Tribal
                             Distribution to the Tribal Enrollment Office

                             Direct Deposit deadline to be received by the Office of Tribal
                             Distribution

December 31st at 12:00pm     Parents of newborns have until this time to submit an Enrollment
                             Application and an Application for Tribal Distribution to the Tribal
                             Enrollment Office

December 31st at 4:30pm      Individuals in the Military or otherwise institutionalized have until
                             this time to submit an Application for Tribal Distribution to the
                             Tribal Enrollment Office

For more information, please contact Barbara Farmer at 601-650-1522 or via email at
distribution@choctaw.org

Yakoki!

				
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