I certify that the information provided in this application is true and complete to the best of my knowledge. I understand that:

• Assistance is available only for qualifying medical travel exceeding 51 miles round trip.

• Assistance is based on the mileage schedule established by the Social Services Department.

• Overnight assistance is limited to $100 per qualifying trip.

• The total Emergency Medical Assistance benefit is limited to $500 per enrolled Tribal member per calendar year.

• Funding is subject to annual budget availability and is not guaranteed.

• Submission of false or misleading information may result in denial of assistance and may affect eligibility for future Tribal assistance programs.