The Erie Indian Moundbuilders Tribal Nation
Statement of Fact
1. I ______________________________________swear the information submitted on my
chart is fact and is true to the best of my knowledge.
2. Information obtained for the Genealogy Ancestry Chart was obtained from
(Check applicable below):
[____] Family Bible
[____] Census (year:________)
[____] Passed down through family
[____] Death Certificate seen but not in possession
[____] Historical Quarterly (where:________________________________________)
Other (explain: attach additional pages if needed:
[____] Other ________________________________________________________________
[____] Other ________________________________________________________________
[____] Other ________________________________________________________________
[____] Other ________________________________________________________________
3. [____] Attach a copy of your Family Tree
Signed______________________________________
State of_______________________________________________
County of _____________________________________________
On
the __________day ________in the year __________personally appeared to me the
above named
____________________________________and acknowledged the forgoing to be
(his/her) voluntary set deed.
Applicants
name:_______________________________
Notary Public for_____________________
Address:_____________________________________
My Commission expires_______________
City:_________________________________________
Phone:_______________________________________
Applicants date of birth:__________________________
Please return application to :
address
address
address
Phone:
Email:
