Individual Tribal Member Requests/Release of Personal Information

Requests for Individual Tribal Member information such as Proof of Residencies, Income
Verifications, or documents from your files or from a deceased family member’s file may take up
to 3 days to receive from the Tribal Office. You must complete the release of information section if
you need your information released out of the Tribal Office. PLEASE NOTE: For proof of residency’s you must provide full address and MUST reside at the address listed.

Tribal Member Name(Required)

Tribal ID #(Required)

Date of Birth(Required)

Date of Request(Required)

Request of Personal Information: (if person is a deceased family member, please state reason why information is being requested)(Required)

Release Information to: (please complete all that apply)

Person or Organization

Fax Number

Person picking up document(s)

I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE STATEMENTS ABOVE ARE TRUE AND CORRECT.

Tribal Member Signature:(Required)

Date(Required)

OFFICE USE ONLY:

Hidden

Request Completed by

Hidden

Date

Hidden

Reason for incompletion of request

Comments

This field is for validation purposes and should be left unchanged.

Contact Information

Cahuilla Band of Indians
52701 US Hwy 371
Anza, CA 92539

Phone | (951) 763-5549
Fax | (951) 763-2808

Individual Tribal Member Requests/Release of Personal Information

Release Information to: (please complete all that apply)

I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE STATEMENTS ABOVE ARE TRUE AND CORRECT.

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