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

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

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

provide thefollowing information for the person submitting this application:

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:

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.

*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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