Po Box 1153 (605) 384-3641 Ext 1036, 1038
Wagner, South Dakota 57380 Fax (605) 384-5895
____________________________ _____ _ ______________________________
Officers: Council:
Robert Flying Hawk Sr, Chairman Quentin Bruguier Sr Jeannie Archambeau, Chairwoman Jason Cooke
Glenford “Sam” Sully, Secretary Everdale Song Hawk
Leo O’Connor, Treasurer Justin Song Hawk
Mona Wright
COMPLETE THIS FORM TO UPDATE ANY INFORMATION REQUIRED IN YOUR ENROLLMENT FILE.**IMPORTANT** ALL NAME CHANGES MUST INCLUDE MARRIAGE LICENSE, DIVORCE LICENSE, LEGAL PAPERS FOR NAME CHANGE. NAME CHANGES WILL NOT BE PROCESSED IF WE DO NOT HAVE THIS PAPERWORK ON FILE.
PLEASE PRINT
ENROLLMENT ADDRESS UPDATE FORM/TRIBAL ID CARD SIGN IN SHEET
You can email or send picture text to
NAME: __________________________________________ HEAD OF HOUSEHOLD ___YES ___NO
DATE OF BIRTH: ______/______/______ PHONE NUMBER_________ __________________________
FORMER/OTHER
NAMES/MAIDEN________________________________________________________________________
SSN#____________________________________________
DO YOU WANT ON SS# ON ID? ___YES ___NO
ADDRESS_______________________________________________________________________________
CITY___________________________________STATE________________ZIP CODE_________________
SIGNATURE OF ENROLLEE___________________________________________ DATE____/____/____
TRIBAL ID’S COST $10.00
ADDRESS MONEY ORDER OR PERSONAL CHECK TO YST ENROLLMENT