BASSC Form - Sign-Up

Boundary and Annexation Survey (BAS)
State Certifying Official Sign-Up Form
The contact information for the individual currently responding to the BAS State Certification
program in your state is provided in the space below:

ST01

Name:

2016

Title:
Department:
Address:
City:

State:

Telephone:

Email:

Zip Code:

State Certification Materials will be mailed to the individual you appoint as the State Certifying Official. You may either
confirm the current State Certifying Official above or appoint another individual to this position. Please provide the
contact information for the appointed State Certifying Official if different from above:
I confirm the contact person listed
above as the State Certifying Official

OR

I appoint the following individual as
the new State Certifying Official:

Name:
Title:
Department:
Address:
City:

State:

Telephone:

Fax:

Zip Code:

Email:
Please sign below to indicate that you approve the information provided on this form.
Governor’s Signature: __________________________________________________
Fax or mail this completed form
To the U.S. Census Bureau:

U.S. Census Bureau
National Processing Center
ATTN: BAS Returns, BLDG 63A
1201 East 10th Street
Jeffersonville, IN 47132

Date:

__________________

Fax Number: 1-800-972-5652

If you have not yet done so, please respond to geo.bas@census. gov with a summary of your state laws regarding
annexations, deannexations, incorporations and disincorporations. These state summary laws will be available on the
BAS website for the 2016 State Certification Program.
A list annexations received through the BAS program from 2000-2015 is available online
at: http://www.census.gov/geo/partnerships/bas/bas_annex.html.