Funeral Potlatch Fund – Tebughna Foundation

Funeral Potlatch Fund

Name of Deceased *

First

Last

Date of Funeral *

Funeral Location *

Address Line 1

Address Line 2

City

State

Zip Code

Amount Requested *

Contact Person *

First

Last

Relatonship to the deceased *

Phone *

Email *

Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Are you a: *

TNC Shareholder
NVT Tribal Citizen
None of the above

Additional Comments

Signature *

Clear Signature