Fillable Form Ind - Tribal Member Certification

Form Ind - Tribal Member Certification - 2012

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Montana

IND

CLEAR FORM

Rev 04 12

2012 Tribal Member Certification

First Name and Initial (as shown on your tribal

Last Name (as shown on your tribal

Social Security Number

enrollment card)

X X X X X X X X X

Mailing Address

City

State

Zip Code

Physical Address (not a post office box)

City

State

Zip Code

Montana Tribe (of which you are an enrolled member)

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,

employer identification

Business name

Please

mark

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 identified above, that

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

information on this form and included with this form is true, correct and complete.

________________________________________________________

____________________________

Tribal Member Signature

Date

*12DK0101*

Form Ind - Tribal Member Certification - 2012

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