Native Village of Eklutna
Enrollment Information Update
Address and Name Change Form
Each person age 18 and older must fill out and sign his/her own form
Name: ___________________________________ Enrollment # (If known) ________________
Date of Birth: ___________________ Social Security # ____________________
Name Change (Previous) ___________________________ (New) ____________________________
Notice: You must provide a copy of your marriage certificate or court order for verification.
New Mailing Address
______________________________ Apt # _____ City ________________ ST ____ Zip __________
Physical Address (If different than mailing address and if mailing address is a PO Box)
______________________________ Apt # _____ City ________________ ST ____ Zip __________
Phone: Home ______________ Cell _______________ Message _______________
Email Address: ________________________________________
If you have MINOR CHILDREN who are enrolled with NVE who have also moved to this same address, please list
their full names, Social Security Numbers and birth dates below, so their addresses can also be changed.
Full Name
Social Security
Number
Birth Date
Son, Daughter, Step
son, Foster daughter,
I do hereby certify that I am the above-named person or the parent/legal guardian of the above-named person and
that all the information is true and accurate.
Signature _______________________________________ Date _____________
Send to Native Village of Eklutna, 26339 Eklutna Village Rd. Chugiak, AK. 99567 or Fax: (907) 688-6021
IMPORTANT: Tribal Member Information is confidential. Mailing lists for newsletters, announcements,
elections, and other official business for the benefit of the tribe are subject to Confidentiality Agreements.
For NVE Enrollment Officer and Administration Use Only
Date Received by NVE Office: _________________ Date submitted to Enrollment Officer: ___________________
Date Mailing Label Updated/Initial: _________________ Date Enrollment Record Updated/Initial: _________________
NVE Document Version 18.11.21
