Request for Certificate of Degree of Indian or Alaska Na

OMB Control #1076-0153

Expiration Date: XX/XX/20XX

BUREAU OF INDIAN AFFAIRS

CERTIFICATE OF DEGREE OF INDIAN OR ALASKA NATIVE BLOOD

INSTRUCTIONS

All portions of the Request for Certificate of Degree of Indian or Alaska Native Blood (CDIB) must be completed. You must show your relationship to an enrolled member(s) of a federally recognized Indian tribe, whether it is through your birth mother or birth father, or both. A federally recognized Indian tribe means an Indian or Alaska Native tribe, band, nation, pueblo, village, or community which appears on the list of recognized tribes published in the Federal Register by the Secretary of the Interior (25 U.S.C. § 479a-1(a)).

 Your degree of Indian blood is computed from lineal ancestors of Indian blood who were enrolled with a federally recognized Indian tribe or whose names appear on the designated base rolls of a federally recognized Indian tribe.

 You must give the maiden names of all women listed on the Request for CDIB, unless they were enrolled by their married names.

 A Certified Copy of a Birth Certificate is required to establish your relationship to a parent(s) enrolled with a federally recognized Indian tribe(s).

 If your parent is not enrolled with a federally recognized Indian tribe, a Certified Copy of your parent’s Birth or Death Certificate is required to establish your parent’s relationship to an enrolled member of a federally recognized Indian tribe(s). If your grandparent(s) were not enrolled members of a federally recognized Indian tribe(s), a Certified Copy of the Birth or Death Certificate for each grandparent who was the child of an enrolled member of a federally recognized Indian tribe is required.

 Certified copies of Birth Certificates, Delayed Birth Certificates, and Death Certificates may be obtained from the State Department of Health or Bureau of Vital Statistics in the State where the person was born or died.

 In cases of adoption, the degree of Indian blood of the natural (birth) parent must be proven.

• Please return your request and supporting documents to the Agency from whom you receive services. Incomplete requests will be returned with a request for further information. No action will be taken until the request is complete.

BUREAU OF INDIAN AFFAIRS

REQUEST FOR CERTIFICATE OF DEGREE OF INDIAN OR ALASKA NATIVE BLOOD

Requester’s Name (list all names by which Requester is or has been known):

Requester’s Address (including zip code):

Date Received by Bureau of Indian Affairs:

Requester’s Date of Birth: Requester’s Place of Birth: Is Requester Adopted?  Yes  No Are Requester’s Parents Adopted?  Yes  No If Yes, list natural (birth) parents: (If known) Tribe(s) with which Requester is enrolled: Roll Nos:	Father’s name: Tribe: Roll No.: DOB: Deceased  Yes  No Year____	Paternal Grandfather’s Name: Tribe: Roll No: DOB: Deceased/Year____ Paternal Grandmother’s Name: Tribe: Roll No: DOB: Deceased/Year____	Paternal Great Grandfather’s Name: Tribe: Roll No: DOB: Deceased/Year____ Paternal Great Grandmother’s Name: Tribe: Roll No: DOB: Deceased/Year____ Paternal Great Grandfather’s Name: Tribe: Roll No: DOB: Deceased/Year____ Paternal Great Grandmother’s Name: Tribe: Roll No: DOB: Deceased/Year____
	Mother’s Name: Tribe: Roll No.: DOB: Deceased  Yes  No Year____	Maternal Grandfather’s Name: Tribe: Roll No: DOB: Deceased/Year____ Maternal Grandmother’s Name: Tribe: Roll No: DOB: Deceased/Year____	Maternal Great Grandfather’s Name: Tribe: Roll No: DOB: Deceased/Year____ Maternal Great Grandmother’s Name: Tribe: Roll No: DOB: Deceased/Year____ Maternal Great Grandfather’s Name: Tribe: Roll No: DOB: Deceased/Year____ Maternal Great Grandmother’s Name: Tribe: Roll No: DOB: Deceased/Year____

SUBMIT TO: BIA AGENCY FROM WHOM YOU RECEIVE SERVICES

OMB Control #1076-0153

Expiration Date: XX/XX/20XX

Page: 2

NOTICES AND CERTIFICATION

NOTICE OF APPEAL RIGHTS.

 When you receive your CDIB, you must review it for the correct name spelling, birth dates, and blood degrees. If you believe that there are any mistakes on the CDIB, you must give a written request for corrections and provide supporting documentation to the issuing officer within 45 days (60 for Alaska tribes) of the date on the letter. If you fail to meet this deadline, appeal rights will be lost. If the issuing officer decides that corrections are not needed, he or she will send a written determination with an explanation through certified mail to you and provide you with a copy of the appeals procedures.

 If you are denied a CDIB, you will be given a written determination with an explanation for the denial and a copy of the appeal procedures.

PAPERWORK REDUCTION ACT STATEMENT

The information collection requirement contained in 25 CFR § 70.11 and this request have been approved by the Office of Management and Budget under the Paperwork Reduction Act of 1995, 44 U.S.C. 3507(d), and assigned clearance number 1076-0153. The agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Information is collected when individuals seek certification that they possess sufficient Indian blood to receive Federal program services based upon their status as American Indians or Alaska Natives. The information collected will be used to assist in determining eligibility of the individual to receive Federal program services. The information is supplied by a respondent to obtain a Certificate of Degree of Indian or Alaska Native Blood. It is estimated that responding to the request will take an average of 1.5 hours to complete. This includes the amount of time it takes to gather the information and fill out the form. If you wish to make comments on the burden imposed by the form, please send them to the Information Collection Clearance Officer, Office of the Assistant Secretary - Indian Affairs, 1849 C Street, NW, Washington, DC 20240. DO NOT SUBMIT YOUR CDIB REQUEST TO THIS ADDRESS; you should instead submit your CDIB request to the BIA Agency from whom you receive services. Note: comments, names and addresses of commentators are available for public review during regular business hours. If you wish us to withhold this information, you must state this prominently at the beginning of your comment. We will honor your request to the extent allowable by law. In compliance with the Paperwork Reduction Act of 1995, as amended, the collection has been reviewed by the Office of Management and Budget, and assigned a number and expiration date. The number and expiration date are at the top right corner of the form.

PRIVACY ACT STATEMENT.

This information is collected pursuant to the Privacy Act, 5 U.S.C. 552a. Pursuant to system of record notice, Tribal Rolls, Interior, BIA-7 (42 FR 19038), the Bureau of Indian Affairs will not disclose any record containing such information without the written consent of the respondent unless the requestor uses the information to perform assigned duties. The primary use of this information is to certify that an individual possesses Indian blood to receive Federal program services. Examples of others who may request the information are U.S. Department of Justice or in a proceeding before a court or adjudicative body; Federal, state, local, or foreign law enforcement agency; Members of Congress; Department of Treasury to effect payment; a Federal agency for collecting a debt; and other Federal agencies to detect and eliminate fraud.

NOTICE OF EFFECTS OF NON-DISCLOSURE.

Disclosure of the information on this CDIB request is voluntary. However, proof of Indian blood is required to receive Federal program services.

NOTICE OF STATEMENTS AND SUBMISSIONS.

Falsification or misrepresentation of information provided on this request is punishable under Federal Law, 18 U.S.C. 1001. Conviction may result in a fine and/or imprisonment of not more than 5 years.

I request a CDIB, and certify that I have read the instructions, and above notices about my request for a CDIB. I further certify that the information which I have provided with this request to the Bureau of Indian Affairs is true and correct.

________________________________________________________ ___________________________

(Requester’s signature) (date)

SUBMIT TO: BIA AGENCY FROM WHOM YOU RECEIVE SERVICES