O
OMB No. _____-____
APPLICATION FOR RELOCATION BENEFITS (Navajo)
FORM: MM#1110.9
INFORMATION ABOUT OUR AGENCY
The Office of Navajo and Hopi Indian Relocation (“ONHIR”) is a Federal Agency in the Executive Branch of the United States Government whose principal office is in Flagstaff, Arizona. ONHIR was created by the Congress in 1974 to assist certain Navajos and Hopis who live on or used to live on lands within what is known as the “Former Joint Use Area” (“FJUA”) which the Federal Court in Tucson awarded to the “other” Tribe in 1978. The FJUA lands awarded to the Hopi Tribe are known as the “Hopi Partitioned Lands” or “HPL.” The lands awarded to the Navajo Nation are known as the “Navajo Partitioned Lands” or “NPL.”
PAPERWORK REDUCTION ACT AND PRIVACY ACT STATEMENT
The Paperwork Reduction Act of 1995 and the Privacy Act of 1974 require that when we ask you for information, we must first tell you our legal right to ask for the information, the reasons why we are asking for it, and how it will be used. We must also tell you whether your response is voluntary, required to obtain or retain a benefit, or mandatory under the law, and what could happen if you do not provide the information. In addition, we must tell you the estimated total time and financial resources required to provide the information, the nature and extent of confidentiality to be provided, and the fact that you do not need to provide the information unless the information collection instrument, in this instance, a form, displays a currently valid OMB control number.
The Navajo—Hopi Settlement Act, 25 U.S.C. 640d et seq., P.L. 93-531, as amended (“the Act.”) authorizes us to collect information from you in order to determine your eligibility to receive relocation benefits. We need this information to assist us in determining where you resided on December 22, 1974; whether you were a Head of Household; when you attained this status and where your were residing at the time among other eligibility issues. You must submit a complete application. If your Application is incomplete, ONHIR will request additional information from you. If you then fail to provide the information requested, the application will be denied.
You are not required to provide the information requested on a federal government form unless the form displays a valid OMB Control Number. The OMB Control Number for this collection is XXX-XXXX. This number is displayed in the upper right corner of the first page of this form.
Generally the Application and other information that you provide us that contains personally identifiable information are confidential under the Privacy Act. There are certain “routine uses” which may be made of the information you provide. Routine uses, with respect to the disclosure of information, are uses compatible with the purposes for which the information was collected. Disclosures outside the Office of Navajo and Hopi Indian Relocation may be made to (1) the Navajo Nation and the Hopi Tribe for use in adjudicating disputes and in determining the configuration of Life Estate Lease parcels, (2) United States Courts concerned with the partition of the Joint Use Area, (3) the Department of Justice when related to litigation or contemplated litigation, (4) appropriate federal, state, local, or foreign agency responsible for investigating or prosecuting violations or enforcing or implementing a statute, rule, regulation, order, or license of information indicating a violation or potential violation of a statute, regulation, rule, order, or license, (5) reports to the United States Congress, and (6) publication of roster to assist potential relocates in determining their application and eligibility status. ONHIR does not establish any minimum period for your retention of documents related to this Application but since you have the burden of proving your eligibility for Relocation Benefits, we urge that you retain such documents until there has been a final determination of your eligibility for such benefits.
The time needed to complete and file an Application for Relocation Benefits will vary depending on individual circumstances. As provided in 5 CFR § 1320.3 (b) (2), the information sought on the Application is information that Applicants can be assumed to have gathered and maintained in the normal course of their lives such as their age, marital status, children and employment and residence history. Consequently it is the Agency’s position that the burden involved in completion of an Application would be limited to the time needed to read the Application; fill in the Application form itself and then transmit it to the Agency. The estimated average time is thirty minutes.
) (1) reviewing instructions - 10 minutes
(2) acquiring, installing, and utilizing technology and systems - 0
(3) adjusting the existing ways to comply with any previously applicable instructions and requirements - 0
(4) searching data sources - 5 minutes
(5) completing and reviewing the collection of information (form) - 10 minutes
(6) transmitting, or otherwise disclosing the information -5 minutes.
There is no submission or filing fee associated with providing this Application form to the Agency. There are miscellaneous costs, including the cost of making photocopies and the cost of faxing or mailing the form to the Agency, associated with this collection, but they are minimal (less than $2.00 per respondent [$.44 postage stamp; $.10 paper; $.02 ink; $.75 photocopies]. We estimate that these miscellaneous costs for all 500 respondents amount to less than $1,000. (500 x $2 = $1,000.)
If you have comments concerning the accuracy of these time estimates or suggestions for making Form MM#1110.9 simpler, we would be happy to hear from you. You can write to ONHIR, P.O. Box KK, Flagstaff, AZ 86002 or fax your comments to 928-774-1977 or e-mail them to [email protected].
PROCEDURES
You are welcome to make an appointment to meet with one of our staff who works on eligibility issues at our Flagstaff office. Having such an in-person meeting with us can be helpful to you, to us and to the eligibility determination process. At such a meeting we will work with you to complete the form; we will try to answer questions you may have and we will ask you questions if we need anything clarified or explained by you. We will also review with you the additional documents you will need to submit which support your Application. While we cannot compensate you for coming to our office for a scheduled appointment, if you do make an appointment and meet with us and if you are eventually certified as eligible for Relocation Benefits, we will be able to reimburse you for some of your travel expenses.
If you would prefer to complete this application and then submit it by mail, fax or e-mail, this procedure is acceptable to ONHIR. To submit an Application by e-mail you will either need to fill in the application on line, download and print it or download and print a blank application form and fill it in. You would then sign the completed application, scan it and attach it to an E-Mail addressed to us.
If you have questions when completing the Application, please give us a call and we can discuss your questions. Our contact information appears later on this form. If you need to meet with an ONHIR Representative and are unable to travel to Flagstaff, please call us as it may be possible for an ONHIR Representative to travel to your residence to meet with you.
If you are not eligible to submit an Application to ONHIR and you send us a completed application, we will communicate with you in writing to inform you that you are not eligible to submit an application and why you are not eligible to submit an application.
Interpretation; Representatives; Special Needs: If an Applicant needs interpretation to the Navajo Language to complete the Application or to answer any questions about the form and our procedure, please let us know what the Applicant’s interpretation needs are and we will do our best to meet those needs. If the Applicant is going to call or visit our office and has such needs, please advise our receptionist of these needs in advance.
If you want us to discuss your application or the facts of your situation with someone else (such as a family member, friend or legal representative) we are glad to accommodate you, but we will need your written authorization to do so.
If you need special assistance in completing this Application, we urge you to contact us and we will do our best to provide the necessary assistance for you to do so. The online PDF version of this Application is readable by standard screen readers.
Appeals:
If you are eligible to submit an application to ONHIR but you are not eligible for relocation benefits and you send us a completed application, we will communicate with you in writing to inform you that you are not eligible for relocation benefits and we will advise you of your rights to appeal that determination.
Contact Information: Office of Navajo and Hopi Indian Relocation
Physical Address: 201 East Birch Ave., Suite 11, Flagstaff, AZ 86001
Mail Address: P.O. Box KK, Flagstaff, AZ 86002
Telephone: 928-779-2721, or 800-321-3114
Fax: 928-774-1977
Website: http://onhir.gov/
e-mail: [email protected]
I. Information About You:
Your Name: ___________________________________
Have you ever been known by any other name? __Yes __No
If “Yes,” what other name? __________________________
Your Date of Birth: ___ / ___ / ____
mm dd yyyy
Your mailing address: __________________________________________
Where you will receive correspondence from ONHIR
Are you an enrolled member of the Navajo Tribe1? __ Yes __ No
If “Yes,” what is your Census Number? _________________
Are you presently a member of any Navajo Nation Chapter? __ Yes __ No
If “Yes,”
Which Chapter? _______________________
In what year did you first become a member of this
Chapter? _______________
Were you ever a member of another Chapter? __ Yes __ No
If you were:
Which Chapter? _______________________
When (what years) were you a member of this Chapter?
From: _________________ To: ________________
CONTACT INFORMATION:
Do you have an E-Mail address? __ Yes __ No
a. If “Yes,” what is your E-Mail address? _______________________
b. If “Yes,” would you prefer that ONHIR send correspondence to your mailing address or e-mail address? __________________
Do you have a home telephone number? __ Yes __ No
a. If “Yes,” may we have the number?
Area Code: _____ Number: _____-________
Do you have a work telephone number? __ Yes __ No
a. If “Yes,” may we contact you at work?
Area Code: _____ Number: _____-_______ x _________
10. Do you have an answering machine or voice mail where we can
leave messages for you? __ Yes __ No
11. If we try to contact you at the above telephone number and are not successful,
is there another number we can call you at or leave messages for you?
__ Yes __ No
a. If “Yes,” what is the other number?
Area Code: _____ Number: ____-______
b. Whose telephone number is this?
______________________________________
II. Please also provide answers to the following:
1. Did you ever apply to ONHIR for Relocation Benefits before this Application? __ Yes __ No
a. If “Yes,” were you the actual Applicant, spouse of the Applicant or a child of the Applicant?
__ Actual Applicant __ Spouse of Applicant __ Child of Applicant
b If “Yes,” When: ________________
c. If “Yes,” under what name did you apply? _________________
d. If, “No,” Why didn’t you apply for Relocation Benefits? ________________________________________________
_________________________________________________
_________________________________________________
2. Where were you living on December 22, 1974?
__ In the Navajo Nation2 __ Outside the Navajo Nation
a. If in the Navajo Nation, in what Chapter? _________________
b. Was the residence located on lands that later became part of the HPL? __ Yes __ No
c. If in the Navajo Nation, please explain where your residence was located:
_______________________________________________________
_______________________________________________________
Continue next page
d. If you had a residence on what became the HPL on December
22, 1974, but were not actually living in that residence on that day, please explain why you were not actually living in that residence, (such as that you were in the military; away at school; employed outside the HPL; etc.) and also tell us where you were living on that day
(1.) Why I was living there:
________________________________________________
________________________________________________
________________________________________________
(2.) Where I was living on December 22, 1974:
_________________________________________________
_________________________________________________
__________________________________________________
4. Have you ever been married? __ Yes __ No
a. If “Yes,” when (what date) were you first married? __ / __ / ____
mm dd yyyy
5. Do you have one or more children? __ Yes __ No
a. If “Yes,” when (what date) was your first child born? __ / __ / ____
mm dd yyyy
6. Did you earn more than $1,300 in one calendar year before 1986?
__ Yes __ No
a. If “Yes,” in what year did you first earn $1,300 or more? ________
b. If “Yes,” for whom did you work? ______________________
________________________________________________
7. If your answer to 6. is “No,” did you earn more than $1,300 from January 1, 1986 to July 7, 1986? __ Yes __ No
a. If “Yes,” for whom did you work? ______________________
________________________________________________
8. What are your parents’ names? ____________________________
_____________________________________________________
9. Have you moved from the HPL? __ Yes __ No
a. If “Yes,” when (what date) did you move? __ / __ / ____
mm dd yyyy
b. If “Yes,” where did you move to? ________________________
c. If “Yes,” why did you move? ____________________________
III. Certification and Execution
I state under penalty of perjury under the laws of the United States of America that the foregoing is true and correct.
__________________________
Signature of Applicant
Signed on: _________________________
Interpreter’s Declaration (use only if the Applicant does not read and write in the English Language)
I ___________________________ am fully fluent in the English and Navajo Languages. At the request of Applicant ___________________ I interpreted the foregoing Application into the Navajo Language to the best of my ability.
I also reviewed the answers given by the Applicant with the Applicant in the Navajo Language.
To the best of my knowledge and belief, the Applicant understood the Application and understood the answers given to the questions in the Application. The answers set forth in this Application are the answers provided by the Applicant.
I state under penalty of perjury under the laws of the United States of America that the foregoing statement is true and correct.
__________________________
Signature of Interpreter
Signed on: _________________________
1 A separate version of this Application is available for members of the Hopi Tribe Form MM#1110.10. If you are a Hopi seeking Relocation Benefits, please let us know and an appropriate Application will be provided to you.
2 For purposes of this question, “Navajo Nation” includes the FJUA.
Applicant Name: _________________________
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | laruzow |
| File Modified | 0000-00-00 |
| File Created | 2021-02-03 |