Change Of Address Form Pokagon Band Of Potawatomi printable pdf download

Change Of Address Form Pokagon Band Of Potawatomi

Pokégnek Bodéwadmik ˑ Pokagon Band of Potawatomi

Tribal Enrollment

58620 Sink Rd. | P.O. Box 180, Dowagiac, MI 49047 | (269) 782-1763· (888) 782-1001· Fax (269) 782-1964

Membership Change of Address Form

INSTRUCTIONS:

Completing this form will officially change the address at which you are currently listed in Tribal records

and for all program mailing purposes. If movng TO any of the 10 county service areas you must provide a valid driver’s

license or state ID bearing the current address and a second proof of residence. If moving OUT of the 10 county service

areas or moving WITHIN the 10 county services areas no additional proof of residence is needed other than this form.

Due to the change of requirements to accomidate Tribal citizens please print clearly to avoid any clerical errors.

LEASE

RINT

LEARLY

Name:

Last

First

Middle

Former Last Name, if newly wed

Membership #

*SS#

(Or)

Date of Birth

Head of Household

Yes

Married / Divorced / Single? :

Military (Active Duty) Yes

Old Address:

(street)

(apt/suite/lot number)

(P.O. Box)

(city)

(state)

(zip)

If you have a Post Office Box for a mailing address, please provide your physical address as well.

New Address:

(street)

(apt/ suite/ lot number)

(P.O. Box)

(city)

(state)

(zip)

( c o u n t y )

Home Phone: (

)

# Unlisted? Yes

Mobile Ph: (

)

(Date)

(Signature)

List minors/spouse living at this address

*indicates Protected Information

Spouse:

Children: 1.

Children: 4.

3.________________________________

6. _______________________________

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Change Of Address Form Pokagon Band Of Potawatomi

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