Tlingit and Haida Indian Tribes of Alaska
Program Compliance Department • Andrew P. Hope Building
320 W Willoughby Avenue, Suite 300 • Juneau, Alaska 99801
AFFIDAVIT For Tribal Identification Card
______________________________________________________________________________________
Last Name First Name Middle Name Suffix
______________________________________________________________________________________
Other Names Used: Tribal Enrollment Number: Birth Date: Soc. Sec. Num.
______________________________________________________________________________________
Mailing Address City, State Zip Code Phone Number
I declare the attached photograph is a true photo of ___________________________________.
Name of person in photo
____________________________________
Parent/Guardian of minor
If you are not a Parent or Guardian please put your
Signature inside the box. This will be used to
Digitize your signature to be captured on you Tribal
Identification Card.
Notice of False or Misleading Information
If any statements are proven to be misleading
or false, penalties may include civil or
criminal charges filed against the provider.
________________________________
Signature
____
____________________________
Date
SUBSCRIBED AND SWORN TO
Before me this______ day of __________ 20 _____
__________________________________________
Notary Public, in and for the State of ____________
Residing at: ________________________________
SEAL My commission expires: ____________________
Original photo Attached Here
This Photo will not be returned.
Please make sure that the Picture has
the Crimp/Stamp at the bottom of the
