Fillable REQUEST & AUTHORIZATION FORM (Susanville Indian Rancheria)

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REQUEST & AUTHORIZATION FORM (Susanville Indian Rancheria)

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Susanville Indian Rancheria Enrollment Office
745 Joaquin Street, Susanville, CA 96130
Phone: (530) 257-2591 | Fax: (530) 257-7986 | Email: iwillard@sir-nsn.gov
REQUEST & AUTHORIZATION FORM
I, , tribal enrollment number _________________,
hereby request the following document(s) for either ☐myself only, ☐myself and for the
following, or ☐the following only: , ,
, , whom
I certify are minor(s) and/or incompetent adult(s) in my legal custody, guardianship, and/or for
whom I have power of attorney.
☐ Tribal ID w/DM Mini-Mart Loyalty Program ☐ Copy of Birth Certificate
☐ Tribal ID Card Only ☐ Copy of Social Security Card (if on file)
☐ Paper Copy of Tribal ID ☐ Family Tree
☐ Membership Verification Form
☐ Tax Exemption Form to purchase: ______________________________
(Not applicable for the purchase of vehicles)
☐ Other ______________________________________________________________________
☐ I further authorize the Susanville Indian Rancheria Enrollment Office to release the
information specified above to the following person and/or organization:
Name:
☐ Pick up at the Tribal Office (Photo ID may be required)
☐ Fax to:
☐ Email to:
Tribal Member Signature Date Phone Number
Mailing Address Street Address (if different)
Email address:
May we add your email address to your enrollment record? ☐ Yes ☐ No
** Office Use Only **
☐ Request made by remote transmission; member identified using the following two or more forms:
☐ DOB ☐ SSN ☐ SIR Roll # ☐ Address ☐
☐ Shred old TID issued on ☐ Cancelled prior RB registration
Enrollment Staff Signature Date
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R:\Templates & Forms\ENR General Forms\ENR Request an
d Authorization Form
FEES
The tribe does not charge a fee for providing any of the items listed on the Request &
Authorization form, unless a previously issued Tribal ID has been lost or stolen.
TRIBAL IDs
New members, or members who have not previously obtained a Tribal ID, must appear
in person at the Enrollment Office to apply for their initial Tribal ID. Be sure to contact
the Enrollment Office to make an appointment if you will be traveling from out of the
area.
When applying to replace a TRIBAL ID card by mail, do one of the following:
• Enclose your old tribal ID card with your Request & Authorization form.
OR:
• If your tribal ID was lost or stolen, enclose a check or money order in the
amount of $15.00, written to Susanville Indian Rancheria, to cover the fee to
issue a replacement Tribal ID. **DO NOT SEND CASH**
WHERE TO FIND FORM
SIR Request & Authorization forms and are available at the Tribal Office or online at
the Susanville Indian Rancheria website:
http://www.sir-nsn.gov/governing-documents/
Contact the Enrollment Office to have the form emailed, faxed, or mailed to you.
WHERE TO SEND FORM
Completed Request and Authorization forms may be returned to the Susanville Indian
Rancheria as follows:
By mail: Susanville Indian Rancheria
c/o Enrollment Office
745 Joaquin Street
Susanville, CA 96130
By fax: 530-257-7986
By email: iwillard@sir-nsn.gov
In person: Susanville Indian Rancheria Tribal Office
If this form is submitted by email, fax, or mail, the requested documents will be sent
to the requestor at the requestor’s address on record with the SIR Enrollment Office.
Tribal IDs, copies of birth certificates, and social security numbers will be sent to the
requestor by CERTIFIED mail.
QUESTIONS
Please call the Enrollment Office at (530) 257-2591 if you have any questions. If the
matter is urgent and the Enrollment Coordinator is not available, contact the Tribal
Office at (530) 257-6264.
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Completed 20 July 2020

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