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Address Change Form -

THE CONFEDERATED TRIBES OF THE WARM SPRINGS RESERVATION OF OREGON

ADDRESS CHANGE FORM

Vital Statistics Department, P O Box C, Warm Springs, Oregon 97761

(541) 553-3252 & 3253, Fax:

(541) 553-1924

PLEASE NOTE ANY CHANGES RECEIVED PRIOR TO THE 10

OF THE MONTH WILL REFLECT IN THE CURRENT MONTH

Requesters Signature:________________________

Date:_____________

Relationship to the person listed below: SELF:____GUARDIAN___Other____

Birth Date:___________________ Enrollment#:_____________

Last Name:_______________________________________

First Name:______________________________Middle Name:_________________

Address:_________________________________________

City:______________________State:______________Zip_________

Phone Number:_(____)___________________

Primary Message Cell

(circle one)

Email:______________________________

_______________________________________________________________________

REASON FOR REQUEST

Pension:______Percapita______

PENSION ONLY

Add Bank: Name of Bank:_______________ Address:__________________

City:____________________ State:___________Zip:__________________

Savings:_____

Checking:________(

Please Provide a voided deposit slip)

Deleting Banking: Name of Bank:__________________________________

Other:

VITAL STATISTICS INFORMATION PURPOSES ONLY:DO NOT FILL OUT THIS AREA

Action Code:___________(A=Add, C=Change)

Date Entered in System:________________

Completed by:__________________________

Address Change Form -