Authorization to Release Information

The Klamath Tribes
Member Benefits Department

501 Chiloquin Boulevard
PO BOX 436
Chiloquin, OR 97624
memberbenefits@klamathtribes.com
Phone: (541) 783-2219 | Fax: (541) 783-7768

Enrollment Ordinance §4.04, Confidentiality

Enrollment documents are confidential unless release is authorized by the applicant or his/her legal guardian.

Member’s Information

Full Legal Name *

First

Middle

Last

Please add Suffix (Sr., Jr., III) after last name.

Other Known Name (eg. Maiden, Indian)

Date of Birth *

SSN# *

Roll#

If this application is being submitted on behalf of a minor or adult under guardianship,

provide thefollowing information for the person submitting this application:

Name

First

Last

Relationship to Applicant

Mailing Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Email

The enrollment record information to be released include(s) the following:

The purpose for this release of information

The enrollment record information will be release by:

The Klamath Tribes Member Benefits Department 501 Chiloquin Boulevard, PO BOX 436, Chiloquin, OR 97624

The enrollment record information will be released to:

Name of Organization *

Type N/A if Not Applicable

Name of Person(s) *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Phone *

Fax#

The record information should be sent by *

Email
Postal Mail
Fax
In-Person

herby voluntarily authorize the release of the above listed information from my enrollment record. I understand this will be a one-time release for the document(s) listed above.

Name *

First

Last

Signature *

Date *

Signed by: *

Applicant
Legal Guardian of Minor*
Legal Guardian of Adult*

*Must ensure legal documentation showing guardianship is on file.

This document was prepared under the provision of the Enrollment Ordinance Klamath Tribal Code Title 1 Chapter 4, approved February 23, 2008 by General Council, Revised September 26, 2013.

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