By my signature below, I attest that the information provided above is true and correct and I am an enrolled member of the Cheyenne and Arapaho Tribes. I understand the OVA staff respects my privacy as a veteran, and will hold in strictest confidence all information disclosed. I understand that no information will be communicated to any NON-Veteran agency without written consent from me, EXCEPT by court order, or in circumstances deemed necessary to avert a crisis. I understand that if I purposely falsify this document and receive funds, I will jeopardize future services with the Cheyenne and Arapaho Tribes. I understand this is not a per capita or stimulus payment and is subject to certification of my military service. I understand that this assistance is provided under the OVA Program, and will not be subject to federal income tax in accordance with the requirements of the federal Tribal General Welfare Exclusion Act of 2014.