Form BLM No. AK-2469 BLM No. AK-2469 Alaska Native Vietnam-Era Veteran Land Allotment Applica

OMB CONTROL NO. 1004-0216
Expires: Month XX, 20XX

UNITED STATES
DEPARTMENT OF THE INTERIOR
BUREAU OF LAND MANAGEMENT
BLM Land Office
ALASKA NATIVE VIETNAM-ERA VETERAN LAND
ALLOTMENT APPLICATION

BLM Serial Number

Act of March 12, 2019. Public Law 116-9, Sec. 1119
1. Name Eligible Individual :

Type or print plainly in ink and sign in ink
(Middle Name)
(Last Name)

(First Name)

Fill in 2 only if you are a Personal Representative of a deceased Eligible Individual or a Guardian/Conservator or have Power of Attorney of the
living Eligible Individual
2. Name of person filing application:
(First Name)
(Middle Name)
(Last Name)

Please circle the appropriate relationship to the Eligible Individual: Personal Representative

Guardian

Conservator

Power of Attorney

3. Mailing Address:

City:

State:

4. Date of Birth of Eligible Individual: month

Zip Code:

day

year

5. Telephone number including area code of person filing application (optional):

6. You must submit a map with your application to show where your claimed allotment is located. Use a topographic map or a similar quality
map. Please provide the following information pertaining to the lands you have selected. If you need help, contact BIA at 1-800-645-8465, your BIA Service
Provider or on the web at: www.blm.gov/ak-native-vietnam-vet-land-allotment-2019.
Sec(s).
, Township
Sec(s).
, Township
Map attached Yes
No

North/South, Range
North/South, Range
.

East/West, Meridian
East/West, Meridian

. Acres
. Acres

.
.

Other descriptive details:
7. Eligible Individual: I meet [the deceased meets] the qualification listed in 43 U.S.C. §1629g-1(a)(2)
a. I am [the deceased was] an Alaska Native as defined in section 3(b) of the Alaska Native Claims Settlement Act (43 U.S.C. 1602(b))
Yes
No
.
b. I am [the deceased was] a Veteran as defined in section 101 of title 38, United States Code
Yes
No
.
c. I [the deceased] served at some point during the time from August 5, 1964 and December 31, 1971
Yes
No
.
d. Do you [Does the deceased] have an active application or have you/the deceased received a conveyance of land in your/their own right
pursuant to:
A. the Act of May 17, 1906 (34 Stat. 197, chapter 2469) (as in effect on December 17, 1971)
Yes
No
.
.
B. section 14(h)(5) of the Alaska Native Claims Settlement Act (43 U.S.C. 1613(h)(5)); or
Yes
No
.
C. section 41 of the Alaska Native Claims Settlement Act (43 U.S.C. 1629g).
Yes
No
.
If lands were inherited lands pursuant to any of the above listed Acts, you are still eligible to apply under this Act.

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8. You are required to provide proof of the Eligible Individual's qualifying military service.
Document attached Yes
No
.
9. You are required to provide proof that the Eligible Individual is an Alaska Native.
No
.
Document attached Yes
10. If the Eligible Individual is deceased, you are required to provide proof of a current appointment as personal representative of
the estate of the deceased Eligible Individual by the proper Alaska State court.
Documents attached Yes
No
.
Not applicable _______________________
11. If you are a guardian/conservator or have power of attorney, you are required to provide proof of a current appointment as
such by the proper Alaska State court.
Documents attached Yes
No
.
Not applicable _______________________
I CERTIFY that the statements made herein are true, complete and correct to the best of my knowledge and belief and are made in good faith.
I understand that providing false statements is a criminal offense and I can be prosecuted pursuant to 18 U.S. Code section 1001.

(Date)

(Signature, mark or thumb print of applicant)

(Date) (Signature of witness) Two witnesses must sign only if applicant endorses application with his mark or thumb print rather than by signature

(Date) (Signature of witness) Two witnesses must sign only if applicant endorses application with his mark or thumb print rather than by signature

All supporting documents must be filed with the application. Any missing documentation may result in the rejection of your application. An application will
not be determined accepted until the application is complete.

NOTICES
PRIVACY ACT STATEMENT
Authority: Public Law 116-9, Sec. 1119, 43 U.S.C. 1629g-1
Principle Purpose: BLM will use the information you provide to process your application and determine if you are eligible to receive an allotment under the Alaska
Native Veterans Allotment Program of 2019.
Routine Uses: BLM will disclose the information according to the release information contained in the regulations at 43 CFR 2.56(d).
Disclosure: Disclosing the information is necessary to receive a benefit. Not disclosing the information may result in BLM rejecting your application.
For additional information, please get information through BLM Alaska's website at: www.blm.gov/ak-native-vietnam-vet-land-allotment-2019
PAPERWORK REDUCTION ACT STATEMENT
In accordance with the Paperwork Reduction Act (44 U.S.C. 3501), the Bureau of Land Management collects information necessary to determine whether or not to
issue an Alaska Native Vietnam Era Land Allotment. Information requested in this form is required to obtain a benefit. According to the Paperwork Reduction Act of
1995, an 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. OMB has approved the collections of information contained in the ePermits System and assigned OMB Control Number 1004-0216.
ESTIMATED BURDEN STATEMENT
Our estimates for public reporting for this collection of information to be 28 hours per response, including time for reviewing instructions, gathering and maintaining data
and completing and reviewing the form. Direct comments regarding the burden estimates or any other aspect of the specific forms to the U.S. Department of the
Interior, Bureau of Land Management, Bureau Clearance Office (WO-630), (XXXX-XXXX), Mail Stop 2134 LM, 1849 C Street, NW Washington D.C. 20240. Please do
not send your completed form to this address.
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Before you send in the application, please check to make sure it is complete and ready to be
sent in

o Did you provide the name of the eligible individual (applicant)
o Did you answer all questions?
o Did you provide your name, address, phone number
o Did you provide the date of birth of the eligible individual
o Did you provide a description of the lands being selected?
o Did you attached the map that you marked the selection on?
If you were required to answer questions 8 and 9;

o Did you attach proof that you are a Vietnam-era veteran?
o Did you attach proof that you are an Alaska native?
If you were required to answer questions 10 or 11;

o Did you attach your current personal representative papers?
o Did you attach your current guardianship papers?
o Did you attach your current conservator papers?
o Did you attach your current power of attorney papers?
o Did you sign and date the application?
If application is endorsed with an X or a thumb print instead of a signature.

o Did two people witness your endorsement?
o Did the witnesses sign and date the application?
o Did you address the envelope with the correct address?
Bureau of Land Management,
ATTN: Alaska Native Vietnam-Era Veterans Land Allotment Section
222 West 7th Avenue, Mail Stop 13
Anchorage, Alaska 99513-7504

o Did you provide a return address on the envelope?
o Did you place the proper postage on the envelope?