Form no. 08915 IS-SD Rev. 3/2017
RELINQUISHMENT OF CITIZENSHIP (MINOR CHILD FORM)
I, _______________________________, do hereby swear or affirm that the following information is true and
correct:
I, ____________________________, state that I am the parent/legal guardian having legal custody of
Print name
________________________________________, a minor child whose birth date is ______________.
First Middle Last
I do hereby relinquish the above named child’s citizenship with the Chickasaw Nation so that I may enroll
this minor child in the ____________________________________________________ tribe. I am making
this relinquishment voluntarily and understand that this terminates the child’s right as a citizen of the
Chickasaw Nation. This relinquishment of citizenship shall become effective on the date that it is received
by the Chickasaw Nation.
Note: If the minor child has been the subject of a legal action, which includes, but is not limited to,
guardianship, divorce, adoption or other child custody proceeding, then a certified copy of the
court order granting legal custody of the minor child must be attached to this relinquishment
form.
Dated this _____ day of __________, 20_____.
Name: _______________________________
Address: _________________________________
_________________________________
Social Security no.: ________________
Child’s
Card returned: Yes No (If No, explain): _______________________________
Minor 12 years of age and older
________________________________________________
Signature of parent/legal guardian
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Subscribed and sworn before me this _____ day of __________, 20_____.
___________________________ _____________________
Notary Public Commission No.
My Commission Expires: _____________________
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FOR ENROLLMENT OFFICE USE ONLY:
Date relinquishment received: ____________________ Received by (initials): _______
Date relinquished: ____________________
