Form no. 08914 IS-SD Rev. 3/2017
RELINQUISHMENT OF CITIZENSHIP (ADULT FORM)
I, ___________________________________________________________, do hereby swear or affirm that
First Middle Maiden Last
the following information is true and correct:
1. I am at least 18 years of age or older.
2. I, ___________________________________________________________, hereby relinquish my
First Middle Maiden Last
citizenship/voter registration with the Chickasaw Nation so that I may enroll in the ________________
____________________________________ tribe. I am making this relinquishment voluntarily and
understand that I will no longer have citizenship or voting privileges with the Chickasaw Nation. This
relinquishment of citizenship shall become effective on the date that it is received by the Chickasaw
Nation.
Dated this _____ day of __________, 20_____.
Name: _______________________________
Address: _________________________________
_________________________________
Birth date: ________________ Social Security no.: ________________
Card returned: Yes No (If No, explain): _______________________________
________________________________________________
Signature of person relinquishing
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Option 1:
Subscribed and sworn before me this _____ day of __________, 20_____.
___________________________ _____________________
Notary Public Commission No.
My Commission Expires: _____________________
Option 2:
Witnessed by the undersigned on this _____ day of __________, 20_____.
___________________________ ___________________________
Signature of witness Printed name of witness
___________________________ ___________________________
Signature of witness Printed name of witness
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FOR ENROLLMENT OFFICE USE ONLY:
Date relinquishment received: ____________________ Received by (initials): _______
Date relinquished: ____________________
