Address Change Request - Minor

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 moving 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 area no additional proof of residence is needed other than this form.

QUESTIONS: Please contact Tribal Enrollment 58620 Sink Rd. | P.O. Box 180, Dowagiac, MI 49047 | (269) 782-1763 | (888) 782-1001 | Fax (269) 782-1964

Last Name*

First Name*

Middle Name

Former Last Name:

Enrollment Number:*

Last Four digits of Social Security Number:

Old Address:

Address Line 1

Address Line 2

City

State

ZIP Code

New Address (Mailing)*

Address Line 1

Address Line 2

City

State

ZIP Code

Address (Physical):

Address Line 1

Address Line 2

City

State

ZIP Code

Please Provide County of Residency:

Phone Number:

Email*

Parent / Legal Guardian:

Relationship to Minor:

Signature

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Date Submitted:

File Upload:

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Please upload supporting documentation

Child 1:

Child 2:

Child 3:

Child 4:

Child 5:

Child 6:

Child 7: