Ka Wai Ola - Office of Hawaiian Affairs, Volume 12, Number 7, 1 July 1995 — Page 9 Advertisements Column 1 [ADVERTISEMENT]

Office use only: Accepted J / Office use only: HCO 95 - Hawaiian Home Lands Trust Individual Claims Review Panel Hawaiian Claims Office CLAIM FORM Name (First, middle, last): Mr. Mrs. Miss Ms. Current Address: Telephone numbers: Home: Work: Other Nos.: Social Security No.: Birthdate: Other names you have used: The statements contained in this claimform are true to the best of my knou>ledge. Signature jyate 1. Status (eheek as many as necessary): I am an eligible beneficiary of the Hawaiian Home Lands trust. I am an: applieanī. hom,esteader. I have not applied for a homestead lease. 2. Type of homestead lease (eheek as many as necessary): pastoral agricultural residential 3. Location of homestead leases involved in this elaim, please give areas and islands: Area: Island: Area: Island: 4. This elaim involves the fo!lowing (eheek as many as necessary): Accelerated (raw land) award Lost application Home construction Position on the waiting list Infrastructure (roads, water, etc.) Successorship Lease document Qualifications as an applicant Loan application or agreement Other, please state: