CTGR SWAP Program Form Please read the S.W.A.P. brochure for the program criteria and guidelines SWAP FormFirst NameMiddle NameLast NameInfoAddress Line 1Address Line 2CityStateZip CodePhone/MobileEmailEnrollment NumberUpload your CIB/Tribal ID if this is your first time submitting a reimbursement.Choose File Birth DateAt time of application are you a Tribal Elder? Yes NoHave you previously applied for assistance? Yes NoMy request falls into the following categories: Healthcare Support Costs (medical bills, dental bills, pharmacy costs, etc) Wellness Assistance (Gym membership, athletic fees, etc) Other (eligibility under HSA regulations)Service RequestsPlease enter the information for each Service Request.Service Date / Time File Upload Service 1Choose File DescriptionDocumentation Submitting: Invoice/Bill ReceiptReimburse or Pay ToAge 55+ at time of service? Yes NoAmountService Date / TimeFile Upload Service 2Choose File DescriptionDocumentation Submitting: Invoice/Bill ReceiptReimburse or Pay ToAge 55+ at time of service? Yes NoAmountService Date / TimeFile Upload Service 3Choose File DescriptionDocumentation Submitting: Invoice/Bill ReceiptReimburse or Pay ToAge 55+ at time of service? Yes NoAmountService Date / TimeFile Upload Service 4Choose File DescriptionDocumentation Submitting: Invoice/Bill ReceiptReimburse or Pay ToAge 55+ at time of service? Yes NoAmountTotalSubmit Form
