Fillable HO-CHUNK NATION POWER OF ATTORNEY (OFFICE OF TRIBAL (Ho-Chunk Nation)

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HO-CHUNK NATION POWER OF ATTORNEY (OFFICE OF TRIBAL (Ho-Chunk Nation)

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1
Office of Tribal Enrollment form 11132019
HO-CHUNK NATION
POWER OF ATTORNEY
(OFFICE OF TRIBAL ENROLLMENT PURPOSES ONLY)
This Power of Attorney is for the purpose of authorizing the designated person to affect business with the Tribal
Enrollment Office on behalf of the following Tribal Member Principal:
NAME: ___________________________________ DOB: ________ TRIBAL ID # 439A00___________________
MAILING ADDRESS: _________________________________________________________________________
CITY: ______________________________ STATE: ___ ZIP: _________County __________________
PHYSICAL ADDRESS: _________________________________________________________________________
CITY: ______________________________ STATE: ___ ZIP: _________ County ___________________
Delegation of Power to Agent
I, designate the following individual as my Power of Attorney (Agent):
(Member Principal Name)
Name of Agent:
Agent’s Address:
Agent’s telephone number:
Agent’s Email Address or additional contacts:
I delegate the following power to my Agent:
(Initial each subject over which you are delegating power to your Agent) By my initial, I grant my Agent the general authority to act for me with
respect to the following (please initial to all that apply):
☐ The power to consent to the disclosure of Enrollment information to the Agent.
☐ The power to request Enrollment Information specific to me, except the Enrollment Office discloses a Social
Security Number only to the Principal, when the Principal is present.
☐ The power to sign and submit a Change of Address to change my address.
☐ The power to sign and submit an Annual Address Verification Form.
☐ Request a duplicate Tribal Identification Card. (Note: All Policies apply and Fees must be paid for by the Agent prior to
issuing a Tribal ID)
☐ Other specifically delegated powers or limits on delegated powers
(Fill in the following spaces or attach a separate sheet describing any other specific powers that you wish to delegate or any limits that you wish
to place on the powers you are delegating.)
☐See attached page(s)
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2
Office of Tribal Enrollment form 11132019
EFFECTIVE DATE AND TERM OF THS DELEGATION
This Power of Attorney takes effect on (day/month/year) , and will remain in effect until
(day/month/year) . .
If a termination date is not provided or if the termination date provided is more than one year after the effective
date of this Power of Attorney, this Power of Attorney will remain in effect for a period of one year after the effective
date, but no longer.
REVOCATION OF POWER OF ATTORNEY
This Power of Attorney may be revoked in writing at any time by the Principal. Such revocation invalidates the
delegation of powers made by this Power of Attorney except for any actions that were already taken prior to revocation.
Upon termination of the Agent’s Authority or when the Agent learns of any event that terminates this Power of
Attorney, the Agent must stop acting on behalf of the Principal. Events that terminate a Power of Attorney or Agent’s
authority include the following:
1. Death of the Principal.
2. The Principal’s revocation of the Power of Attorney or your authority.
3. The term of this Delegation period is expired.
NOTARIZATION OF SIGNATURE OF PRINCIPAL
____________________________/________________________________ _____________
Principal Printed Name / Signature Date
___________________________/________________________________ _____________
(Optional) Witness Printed Name / Signature Date
IN WITNESS WHERE OF, in the State of _______, County of___________________________ this document was
signed before me on this __________ day of __________________ in the year _______.
________________________________________
Signature of Notary Public Notary Public Seal
My Commission expires ____________________________
3
Office of Tribal Enrollment form 11132019
STATEMENT OF AGENT
When the Agent accepts the authority granted under this Power of Attorney, a special legal relationship is created
between the Agent and the Principal. This relationship imposes legal duties that continue until the Agent resigns, the
POA is terminated, is revoked or expires.
Agent must do all the following:
1. Act in good faith and in the best interests of the Principal
2. Execute nothing beyond the authority granted by the Principal in this Power of
Attorney.
3. Disclose your identity as an Agent whenever you act for the Principal.
Liability of Agent: The Agent shall be held liable if there is a breach of the Agent’s duties as outlined in the General
Authority section above especially for any breach of fiduciary duties by the Agent.
Photo Copies: Photocopies of this document can be relied upon as though they were originals.
I, __________________________________________, understand that ___________________________________
Agent Principal
has delegated to me, the powers specified in this Power of Attorney regarding the care and management of his/her
Tribal Enrollment Information and business. I further understand that this Power of Attorney may be revoked in
writing at any time by the Principal and that this Power of Attorney expires upon the one year anniversary of signing
or upon the death of the Principal, whichever occurs first.
I declare that I have read this Power of Attorney, understand the powers delegated to me by this Power of Attorney, I
am fit, willing and able to undertake those powers and accept those powers in good faith.
NOTARIZATION OF SIGNATURE OF AGENT
Agent Printed Name:
Address:
Telephone number / Email Address (other Contact):
,
Agent Signature Date
IN WITNESS WHERE OF, in the State of _______, County of___________________________ this document was
signed before me on this __________ day of __________________ in the year _______.
________________________________________
Signature of Notary Public Signature Notary Public Seal
My Commission expires_____________________________
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HO-CHUNK NATION POWER OF ATTORNEY (OFFICE OF TRIBAL (Ho-Chunk Nation)

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Completed 23 December 2020

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