"Request Form for Confidential Information - White Earth Reservation Tribal Council Tribal Enrollments" - Minnesota

White Earth Reservation Tribal Council Tribal Enrollments

REQUEST FOR CONFIDENTIAL INFORMATION

P.O. Box 506

Phone: (218) 983-3285

White Earth, Minnesota 56591

Fax:

(218) 983-3707

REQUEST FOR:

[ ] Indian Preference BIA Form 4432

[ ] Certificate of Degree of Indian Blood (CDIB)

[ ] Tribal Enrollment Card

[ ] Other (explain): ___________________________________________________________________

** NOTE: For proof of decendency, please use the Request for Verification of Decendency Form

IDENTIFICATION:

Name: ______________________________________________________________________________

(First)

(Middle)

(Maiden)

(Last)

DOB: _____________________________

(Month)

(Day)

(Year)

Current Mailing Address:

____________________________________________________________________________________

(Address)

(City)

(State)

(Zip)

** NOTE:

This address will be used to update your Enrollment record if it is different than what we have on file

Telephone Number: ____________________________________________

If request is for a minor, proof of legal guardianship must be included such as certified birth certificate

along with documentation of any name change(s):

Relationship: ______________________________

Print Name of Requestor: ________________________________________________________________

Signature: __________________________________________________

Date: ____________________________________