Deceased Benefits Application

The Klamath Tribes
Member Benefits Department

501 Chiloquin Boulevard
PO BOX 436
Chiloquin, OR 97624
memberbenefits@klamathtribes.com
Phone: (541) 783-2219 | Fax: (541) 783-7768

Deceased Benefits Application


In the event an enrolled Tribal Member becomes deceased during the year Per Capita payment is distributed, the deceased Per Capita payment shall be delivered to the court appointed representative of the deceased’s estate.

Deceased’s Information

Deceased’s Family Information

Type N/A if Not Applicable

10. Name(s) of Surviving Children:

Type N/A if Not Applicable
Type N/A if Not Applicable
Type N/A if Not Applicable
Type N/A if Not Applicable

11. Name(s) of Living Parent(s):

Type N/A if Not Applicable
Type N/A if Not Applicable

By signing this document, I certify that the information provided is accurate and true to the best of my knowledge.

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