Fillable Form Montana Ind - Tribal Member Certification

Form Montana Ind - Tribal Member Certification - 2010

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CLEAR FORM

MONTANA

IND

Rev 11 10

2010 Tribal Member Certiﬁ cation

Your last name as shown on tribal enrollment card

First name and initial as shown on

Your social security number

tribal enrollment card

Your mailing address

City

State

Zip Code

Your physical address (not a PO Box)

City

State

Zip Code

Montana tribe of which you are an enrolled member

Your tribal enrollment number

Reservation(s) on which you resided during tax year

Dates

Employer Information: Please see instructions.

Self-employed?

Employer’s federal

Street address, city, state,

Business name

Please check

employer identiﬁ cation

Dates employed

and zip code (not a PO Box)

box

number (FEIN)

I declare under penalty of false swearing that I am an enrolled member of the tribe identiﬁ ed above, that

I possess the full rights of tribal membership, that I reside on the reservation identiﬁ ed above and all the

information on this form and any attachments to this form is true, correct and complete.

________________________________________________________

____________________________

Tribal Member Signature

Date

*12150101*

1215

Form Montana Ind - Tribal Member Certification - 2010

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