Fillable CDIB/Membership If 14 years of age & older, (Choctaw Nation)

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CDIB/Membership If 14 years of age & older, (Choctaw Nation)

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Veteran/Active Duty? Yes No (circle one) If yes, please provide documentation for veteran status to be displayed on card
I certify that the information given in this application is true. I am eligible to be a member of the Choctaw Nation of
Oklahoma as defined in the Constitution of
the Choctaw Nation of Oklahoma. I
understand that false or erroneous
information can cause loss of membership. I am not a
registered
member of another tribe, nor am I registered to vote with
another tribe.
I am requesting:
First Time CDIB/Member
CDIB/Membership with Photo
CDIB/Membership without Photo
Replacement/Update CDIB/Member
CDIB/Membership with Photo
CDIB/Membership without Photo
Address change only (no card issued)
Please complete one (1) for ALL applicants. If under 14 years of age, a parent or guardian will
need to sign.
If 14 years of age & older, the applicant must sign for himself/herself (if photo is requested on card).
_________________________________________________________________________________________________________________
First Name (please print) Middle Last Maiden
_________________________________________________________________________________________________________________
Physical Address Mailing Address (if different) City
_________________________________________________________________________________________________________________
State Zip Code County Phone Number
_________________________________________________________________________________________________________________
Birthday Gender Social Security Number Email
Signature______________________
________ Date_______________________
(indicate relationship if other than applicant)
CHECKLIST
First time CDIB/Member (with or without photo)
Replacement/Update CDIB/Member (with or without photo)
CDIB/Membership application (pages 1-4)
Original state full form birth certificate
Sworn Statement Affidavit (signed by Native American
parent(s) and notarized)
Copy of social security card
Passport style photo (for those 14 and older & applying
for CDIB/Membership with photo card)
Secondary identification (for those 14 and older &
applying for CDIB/Membership with photo card)
CDIB/Membership application (page 1 only)
Passport style photo (for those 14 and older & applying
for CDIB/Membership with photo card)
Secondary identification (for those 14 and older &
applying for CDIB/Membership with photo card)
* For all CDIB/Membership cards, the applicant must be verified. You
may receive a letter requesting additional documentation.
Page 1
__________________________________________________________________________________________________________________________
For Office use only: Verified? Yes No CN_____________ ID# ____________ Clerk___________
CDIB/Membership
Choctaw Nation of Oklahoma
PO Box
1210 Durant, OK 74702
Phone: (580) 924-8280 or (800) 522-6170 ext. 4030
F
ax: (580) 920-7001
Email: cdib-membership@choctawnation.com
**Please see attached FAQ for further detailed
instructions
Certificate of Degree of Indian Blood Card Application for the Choctaw Nation of Oklahoma
Date: _____________________________
___________________________________________________________
Address City State Zip
Is applicant adopted? Yes____ No____
If answer is yes, list natural parents. See instructions on 2
nd
page in case of adoption.
*Incomplete applications will be returned
**Follow Indian blood lines only using maiden names for females
X_______________________________________________________________
Signature of applicant, or parent or guardian of minor
(Indicate relationship if other than applicant)
ALL CDIB Applications Must be signed.
CDIB Cards WILL NOT be issued without a signature.
CDIB ( ) YES ( ) NO
Paternal Grandfather:
_________________________
Tribe:____________________
Date of Birth______________
Date of Death_____________
Paternal Great-Grandfather:
________________________________
Tribe & Roll # _____________________
Date of Birth__________Death___________
Paternal Great-Grandmother:
________________________________
Tribe & Roll # _____________________
Date of Birth________Death_________
CDIB ( ) YES ( ) NO
Paternal Grandmother:
_________________________
Tribe:____________________
Date of Birth______________
Date of Death_____________
Paternal Great-Grandfather:
________________________________
Tribe & Roll # _____________________
Date of Birth__________Death___________
Paternal Great-Grandmother:
________________________________
Tribe & Roll # _____________________
Date of Birth________Death_________
CDIB ( ) YES ( ) NO
Father:
____________________________
Tribe:_______________________
Date of Birth_________________
Date of Death________________
CDIB ( ) YES ( ) NO
Mother: (Maiden name)
____________________________
Tribe:_______________________
Date of Birth_________________
Date of Death________________
CDIB ( ) YES ( ) NO
Maternal Grandfather:
_________________________
Tribe:____________________
Date of Birth______________
Date of Death_____________
Maternal Great-Grandfather:
_________________________________
Tribe & Roll # _____________________
Date of Birth__________Death___________
Maternal Great-Grandmother:
________________________________
Tribe & Roll # _____________________
Date of Birth________Death_________
CDIB ( ) YES ( ) NO
Maternal Grandmother:
_________________________
Tribe:____________________
Date of Birth______________
Date of Death_____________
Maternal Great-Grandfather:
________________________________
Tribe & Roll # _____________________
Date of Birth__________Death___________
Maternal Great-Grandmother:
________________________________
Tribe & Roll # _____________________
Date of Birth________Death_________
***Please provide additional
lineage on separate sheet, if
necessary
________________________________
Applicant Name
________________________________
Date of Birth
________________________________
State of Birth
Page 2
PLEASE READ THIS ENTIRE PAGE FOR IMPORTANT INFORMATION REGARDING
CDIB APPLICATION REQUIREMENTS
CERTIFICATE OF DEGREE OF INDIAN BLOOD
The application for Certificate of Degree of Indian Blood (CDIB) must be completed showing your DIRECT lineage to an
original enrollee on the Final Choctaw Dawes Rolls, registered with a blood quantum. (Please use both married
and maiden names for females).
The DAWES COMMISSION ROLL BOOK, the FINAL ROLL of the Five Civilized Tribes, which is used for establishing CDIB,
was compiled primarily during the years of 1899-1906. Anyone who died before 1899 or was born after March 4, 1906
DOES NOT HAVE A ROLL NUMBER.
You can have more than one tribe listed on your CDIB card if it is one of the other Five Civilized Tribes (Creek,
Chickasaw, Cherokee, and Seminole) and you or your parent(s) have already been established with that tribe.
DOCUMENTS REQUIRED TO PROCESS APPLICATION
 An ORIGINAL state certified (full form) birth certificate (both sides) is required for each applicant. If anyone in your
immediate family or your direct lineage has been issued a CDIB card previously, the required birth/death certificates
may already be on file in the CDIB office. However, if you have received a letter requesting documentation, then we
have already researched and do not have them on file. If no one in your direct lineage has ever been issued a CDIB,
you will need to provide ORIGINAL state certified full form birth/death certificates (both sides) for each person in your
lineage back to, and including, the enrollee.
 Delayed birth/death certificates and computerized/electronic birth certificates require additional supporting
documentation.  (see Sworn Statement Affidavit faq).
 If you are adopted, you must trace your Choctaw blood through your natural (biological) parent(s). We will need
the ORIGINAL state certified full form birth certificate (after adoption) and a copy of the adoption decree. If the
adoption decree does not show the natural parent(s), you will also need to submit one of the following: (1) A copy of
your birth certificate before adoption, showing natural parent(s) name(s) or (2) a copy of the Petition to adopt, that
specifically names your natural (biological) parent(s). Additional documentation may be required.
 Certified copies of birth certificates, delayed birth certificates, and death certificates may be obtained from the State
Bureau of Vital Statistics in the state in which a person was born or died. DO NOT go online to obtain a state birth
certificate as it may result in acquiring the wrong form.
_________________________________________________________________________________________________
All applications must be accompanied by the required state certified birth/death certificates.
The state issued birth/death certificate must show full parentage and must be signed by the state registrar.
All birth certificates must display a state file number.
Mail completed applications and required documents to:
Choctaw Nation of Oklahoma
CDIB office
P.O. Box 1210
Durant, OK 74702
Questions? Call toll free (800) 522-6170
WE DO NOT ACCEPT HOSPITAL, CITY, COUNTY
OR STATE SHORT FORM BIRTH
CERTIFICATES.
or (580)924-8280 ext 4030 Fax: (580) 920-7001
Page 3
SWORN STATEMENT AFFIDAVIT
I, ________________________________________, do solemnly swear that I am the natural mother of
Mother (full maiden name, as it appears on birth certificate)
___________________________________________________
whose date of birth is ____________________; and that
Child (full name, as it appears on birth certificate)
_____________________________________ is the natural father of my child. This birth occurred in
Father (full name, as it appears on birth certificate)
__________________________________.
(City and state)
____
______________________________________________
Signature of natural mother
__________________________________________________
Printed name
__________________________________________________
__________________________________________________
Mailing address
__________________________________________________
__________________________________________________
Physical address
H: ____________________
___C:_______________________
Phone number
Subscribed and sworn to me
this ____ day of _____________, 20____.
Notary: _______________________________
commission expires: __________________
Commission No: ________________________
__________________________________________________
Si
gnature of natural father
__________________________________________________
Printed name
__________________________________________________
__________________________________________________
Mailing address
__________________________________________________
__________________________________________________
Physical address
H: ______________________C:________________________
Phone number
Subscribed and sworn to me
this ____ day of _____________, 20____.
Notary: _______________________________
commission expires: __________________
Commission No: ________________________
Whoever, in any matter within the jurisdiction of any department or agency of the United States knowingly and willfully falsifies, conceals or
covers up by any trick, scheme, or device or material fact, or makes any false, fictitious or fraudulent statements or representations, or makes or
uses false writing or document knowing the same to contain any false, fictitious or fraudulent statement or entry, shall be fined not more than
$10,000 or imprisoned not more than five years or both.
June 25, 1948, C. 645, 62 Stat. 749.
Page 4
Print
FAQ and Instructions
WHAT IS THE CDIB/MEMBERSHIP CARD? The CDIB/Membership is a card that combines the Certificate of Degree
of Indian Blood (CDIB), Membership, and Photo ID (if photo is submitted) into one card.
WHAT IS REQUIRED TO GET THE CDIB/MEMBERSHIP CARD? In order to be issued a CDIB/Membership card,
members and new applicants must be verified. This means that all correct birth and death certificates, as well as
any additional required documents in an individual’s lineage back to and including the Dawes enrollee, must be on
file.
WHAT ELSE AM I REQUIRED TO PROVIDE? At least one additional form of photo identification is needed to prove
identity and obtain the new CDIB/Membership card. Accepted forms of identification are a current state issued
driver’s license, state issued ID card, passport, military ID, employee photo ID or school issued photo ID. (please send
a copy of the ID)
WHAT PHOTOS ARE ACCEPTABLE FOR THE CDIB/MEMBERSHIP WITH PHOTO CARD? Please send in a passport style
photo. It should be a head and shoulders, only, ƉŚŽƚŽ with a ǁŚŝƚĞͬďĞŝŐĞͬŐƌĂLJƐŽůŝĚcolored background, no glasses
or hats. Faxes or copies of photos will not be accepted. Only photos mailed in with applications (please write name
and birth date on the back of each photo), emailed with applications, or walk-ins at the Membership office will be
accepted. If a photo is not supplied, members will be issued a CDIB/Membership card without a photo.
Please refer to this website for photo requirements:
https://travel.state.gov/content/travel/en/passports/requirements/photos.html
CAN MY CHILD GET A CDIB/MEMBERSHIP WITH PHOTO CARD? Children under 14 years of age will be issued a CDIB/
Membership card without a photo. Once they have reached age 14, they will be eligible to receive the CDIB/
Membership card with Photo. (14 and up with photo: the applicant's signature is required)
DOES THE CARD EXPIRE? The CDIB/Membership card will expire five years from the date of issue. At this time, your
photo and information should be updated. (this does not mean you are no longer a member)
WHAT IF I LOSE MY CARD BEFORE IT EXPIRES? One replacement card will be issued during the five year expiration
period.
WHAT IF MY ADDRESS CHANGES? If you have an address change, please submit a CDIB/Membership application and
a new card will be issued to you.
WHAT ABOUT A NAME CHANGE? In cases of legal name change and adoption, please submit a CDIB/Membership
application along with court documents and the new birth certificate.
_______________________________
WHAT IS A SWORN STATEMENT AFFIDAVIT (SSA)? A Sworn Statement Affidavit is used as a supporting document to
birth certificates that require additional verification, such as computerized, delayed, and birth abroad.
WHO IS REQUIRED TO SIGN THE SSA? Only the Native American parent is required to fill out, sign and have the
document notarized. If both parents are Native American, both are required.
IS THERE A CERTAIN WAY TO FILL OUT THE SSA? Please take care when filling out the top five spaces of the SSA, they
need to be written exactly as they are entered on the birth certificate. Please make sure that the mother's maiden last
name is used instead of her married last name.
_______________________________
*A copy of your social security card is now required when you file for a CDIB. Please list your entire social security
number on all paperwork.
Page 5
Voter Registration Form
CHOCTAW NATION OF OKLAHOMA
PO Box 1210 Durant, OK 74702
Phone: (580) 924-8280 or (800) 522-6170, ext. 2289, 2410, 5190
Email: voterregistration@choctawnation.com
First Name (please print) Middle Last/Suffix Maiden
Birth Date Last 4 Digits of Social Security Number Phone Number Email
Street or 911 Address City State Zip Code County
OR, Provide Physical Directions to your home from the nearest town/city or major highway
(A physical address must be provided in order to register)
Mailing Address (if different than above) City State Zip Code
DISTRICT AFFILIATION
NON-RESIDENTS ONLY: If you live outside of the Choctaw Nation boundaries, you may affiliate with ONE of the districts below, however, it is not required. If you
affiliate with a district, you will be mailed a ballot when there is a Tribal Council Member election for that district. Once you affiliate you must remain in the district
you have chosen, unless you move within the Choctaw Nation boundaries. If you choose not to affiliate, you will only be mailed a ballot when there is an election for
Chief of the Choctaw Nation.
PLEASE CHECK THE DISTRICT YOU WOULD LIKE TO AFFILIATE WITH OR if you prefer “NOT TO AFFILIATE” with a particular district, then you may check this box
instead: ☐ I choose not to affiliate at this time
☐ District 1
☐ District 2
☐ District 3
☐ District 4
☐ District 5
☐ District 6
☐ District 7
☐ District 8
☐ District 9
☐ District 10
☐ District 11
☐ District 12
RESIDENTS: Residents of the Choctaw Nation 10 ½ county service area (below) will be assigned to vote in the district in which they reside.
ADDRESS RELEASE AUTHORIZATION
Would you like your name and address released to candidates who run for Choctaw Nation Chief and Tribal Council?
☐ YES (I want my name and address released) ☐ NO (I do not want my name and address released)
Signature of Applicant - Forms without signature will not be processed
FOR DEPARTMENT USE ONLY
Record ID: Date Processed/Initials: District Assigned: Date Scanned/Initials:
I certify that the information given on this application is true.
I am eligible to be a registered voter of the Choctaw Nation
as stated in the Constitution of the Choctaw Nation of
Oklahoma. I understand that false or erroneous information
can cause loss of voting privileges. I am not a member of
another tribe, nor am I registered to vote with another tribe.
Choctaw Nation
of Oklahoma
District Boundaries
Date: / /
Sign Here
V2.02022017
WEBSITE: WWW.CHOCTAWNATION.COM/VOTE
General Instructions
Use Blue or Black Ink to Complete This Form.
When to Use the Voter Registration Form
1
st
time registration for Choctaw Nation Tribal Elections.
Update a Phone Number or Email.
Update a physical address and/or mailing address.
Update an Address Release Authorization.
Eligibility Checklist for Voter Registration
☐You are a Tribal Member of the Choctaw Nation of Oklahoma.
☐You are or will be 18 years of age or older on the day of the next tribal election.
☐You have fully completed your Voter Registration Form, with emphasis in the following areas:
You provided your physical address. (Please see guidelines below)
If you have a street address or 911 address, this is your physical address.
A rural route, highway contract, or a post office box is NOT a physical address.
If you do not have a street address or 911 address, you may write directions to your
home from the nearest city/town or major highway.
You signed your form.
How to Submit the Voter Registration Form
Deliver in person to the Voter Registration Department. Our hours of operation are Monday
through Friday, excluding tribal holidays, from 8am to 4:30pm.
Email to VoterRegistration@choctawnation.com.
Mail to following address:
Choctaw Nation of Oklahoma
Attn: Voter Registration
PO Box 1210
Durant, OK 74702
What to Expect After You Submit Your Voter Registration Form
You will be mailed a Voter Registration Certificate once your form has been processed. You may retain
the Certificate for your records or use the back of the Certificate to update your voter registration.
Voter information is not shared with other service programs of the Choctaw Nation of
Oklahoma.
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CDIBMembership If 14 years of age & older, (Choctaw Nation)

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Completed 13 March 2021

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