Request for Verification of Tribal Membership and Territorial Jurisdiction
Office of Child Support
Date:
To:	KBIC Office of Child Support Services
16429 Bear Town Road	Phone:	906-353-4566
Baraga, MI 49908	Fax:	906-353-8132
From:
MDHHS Office of Child Support (OCS)
Re:
Michigan IV-D Case Number/Application Number
Please check your records and verify the Tribal membership and Tribal territorial jurisdiction for the individuals listed on the attached form. Complete the form and return it to the Office of Child Support by
using the fax number provided.
(date)
Your prompt cooperation in this matter is greatly appreciated. If you have questions or need additional information, please contact the Office of Child Support at 866-540-0008.
The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability.

PERSONAL DATA AND TRIBAL ENROLLMENT VERIFICATION
A. PERSONAL DATA AND TRIBAL ENROLLMENT VERIFICATION (OCS completes 1-3; KBIC completes 4 and 5)
1. Name	2. DOB	3. SSN	4. Tribal Membership Number	5. In KBIC Territorial Jurisdiction?
CP	Yes	No
NCP	Yes	No
CH	Yes	No
CH	Yes	No
CH	Yes	No
CH	Yes	No
B. TERRITORIAL JURISDICTION (KBIC completes “B”)
At least one person listed above is a Tribal member, and at least one person listed above is living within the territorial jurisdiction of the Keweenaw Bay Indian Community. This case qualifies as a Tribal IV-D case.
No person listed above is a Tribal member living within the territorial jurisdiction of the Keweenaw Bay Indian Community. This case does not qualify as a Tribal IV-D case.
C. INFORMATION PROVIDED BY (KBIC completes “C”)
Name of person completing this form (Print)	Title
Agency
Signature	Date
D. RETURN FORM TO
Phone Number	Fax Number
Notes