Form BAS-1 BAS 1 - Place Form

BAS-1

FORM
OMB Control No. 0607-0151
Expiration Date: XX-XX-XXXX

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU

BOUNDARY AND ANNEXATION SURVEY (BAS)
INCORPORATED PLACES
Boundaries as of —
To report boundary changes for your incorporated place, please complete this form.
GENERAL
INSTRUCTIONS

• It is important that all questions on the form are answered completely.
• If there are no boundary changes to report, please email [email protected]. call 1–800–972–5651, or respond
electronically at https://www.census.gov/programs-surveys/bas.html.
• Please do not return all of the maps. Sign and return only the maps with changes.
• Return the completed form(s) and updated map(s) using the return label.
• For further instructions on filling out this form, please refer to the BAS Respondent Guide.
State

A. Incorporated place

Type

B. County(ies), parish(es), borough(s), or other statistically

C. Minor civil divisions (code)

equivalent area(s) (code)

BAS ID
Question 1

PLACE
CODES

STATE
CODE

ANSI

FIPS

NAME, TYPE, COUNTY, OR MINOR CIVIL DIVISION CHANGE – Please mark (X) the appropriate boxes.

1a. Are the name and descriptor (i.e., city, town, village, borough) of this incorporated place correct as shown in box A, at
the top of the page?

Effective date of change

Yes – Continue with question 1b.
No – Enter correction here.

Name:

Type:

Date: (Month/Day/Year)

1b. Is the list of the county(ies) or equivalent area(s) and minor civil division(s) within which this incorporated place is
located correct as shown in boxes B and C, at the top of the page?
Yes – SKIP to question 2.
No – Enter correction(s) in question 1c.
1c. Enter the correct information AND the effective date of the change.
Attach additional correction information on a separate sheet.
A – Add
D – Delete

Name of county or equivalent area

Minor civil division

Effective date of change
Month Day
Year

1.
2.
3.
4.
We estimate that completing this form will take 30 minutes on average. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, to [email protected]. This collection has been approved by the Office of Management and Budget (OMB). The eight digit
OMB approval number that appears at the upper left of the form confirms this approval. If this number were not displayed, we could not conduct this survey. The Census
Bureau conducts this program under the legal authority of the Title 13 U.S. Code, Section 6.

Question 2

CONTACT INFORMATION – Please fill in your contact information in the space provided below.
BAS Respondent

Mailing
Address

Mark (X) one government type for the BAS Respondent.

(The BAS Respondent is the person filling out this form.)

Local

County

Regional

Name
Address
Position
Department

City

Telephone

(

)

Fax

(

)

Ext.

State

ZIP code

E-mail

Mark (X) this box if the BAS Respondent is
the same as the BAS Mailing Contact.

Question 3

Mark (X) this box if the BAS Respondent is
the same as the Highest Elected Official.

CONTACT INFORMATION – Please fill in or correct the contact information below.
Mark (X) one government type for the BAS Mailing Contact.

BAS Mailing Contact

Mailing
Address

(Provide address where BAS materials should be sent.)

Local

County

Regional

Name
Address
Position
Department

City

Telephone

(

)

Fax

(

)

Ext.

State

ZIP code

E-mail

Highest Elected Official

Mailing
Address

(for incorporated place only)

Name
Address
Position
Department

City

Telephone

(

)

Fax

(

)

Ext.

ZIP code

State
E-mail

RETURN FORMS TO:
U.S. Census Bureau
National Processing Center
ATTN: BAS RETURNS, BLDG 63E
1201 East 10th Street
Jeffersonville, IN 47132

Questions?

Telephone: 1-800-972-5651

REMINDER: Sign and date the signature box on all updated map sheets.

Thank you for your participation and timely response.
E-mail: [email protected]

website: https://www.census.gov/programs-surveys/bas.html
CENSUS USE ONLY

SPECIAL INSTRUCTIONS (If any)

FORM BAS-1 (11-16-2016)

Date
processed

Clerk ID
processed

Date
verified

Clerk ID
verified

Date form
keyed

Date GPP
updated

S/S change

Map received

Map
change

S/S no
change

Other map

Map no
change

PLAT/
Description

Map
signed

Letter

IMPORTANT – ANNOTATE EACH CHANGE ON THE MAP(S) WITH THE APPROPRIATE DOCUMENTATION
ACCORDING TO THE INSTRUCTIONS PROVIDED IN THE BAS RESPONDENT GUIDE.
Please update the map(s) USING THE APPROPRIATE COLORED PENCILS.

Question 4

LEGAL BOUNDARY CHANGES – Please mark (X) the applicable box(es).
Time period

4a. Have there been any legal boundary changes to this incorporated place during the time period shown above?
Yes – Please record all legal changes (annexations, deannexations, and other actions) in the Documentation of Changes
section of this form and update the map(s) USING THE ENCLOSED RED PENCIL. Continue with question 4b.
No – Continue with question 4b.
4b. Are there any legal boundary changes that occurred before the period shown above that do not appear on the enclosed map(s)?
Yes – Please record all legal changes (annexations, deannexations, and other actions) in the Documentation of Changes
section of this form and update the map(s) USING THE ENCLOSED RED PENCIL. Continue with question 4c.
No – Continue with question 4c.
4c. Has your incorporated place had any other types of changes (i.e. consolidations/mergers, been annexed, been
dissolved/disincorporated, etc.) that have affected its boundaries or governmental status during the time period shown above?
No – SKIP to question 5.

Yes – Complete question 4d.
4d. This place has: Mark (X) one of

(Month/Day/Year)
Ordinance/Resolution No.

Government

the following

Name of government with which place consolidated/merged

(1)

consolidated/merged with

Number

. . . .
Name of government annexing this incorporated place

(2)

Date
Number

been annexed by . . . . . . . . . .
Name of government being dissolved/disincorporated

(3)

dissolved/disincorporated

Date

Date
Number

. . . .

Date

(4)

Number

Other – Provide an explanation.

Question 5

OTHER CHANGES – Mark (X) applicable box(es).

5a. Besides legal changes, are there any boundary corrections that need to be made to your boundary on the map(s)?
Yes – Please correct the map(s) USING THE ENCLOSED RED PENCIL and the letters "BC" to indicate a boundary correction.
Enter the total number of boundary corrections that you made to the maps.

Continue with question 5b.

No – Continue with question 5b.
5b. Did you add, delete, or make any changes to the features (other than boundaries) shown on the map(s)?
Yes – Correct the map(s) USING THE ENCLOSED PURPLE PENCIL. Continue with question 5c.
No – Continue with question 5c.
5c. Did you make any changes to the addresses shown on the map(s)?
Yes – Correct the map(s) USING THE ENCLOSED PURPLE PENCIL.
No
REMINDER: Sign and date the signature box on all updated map sheets.
FORM BAS-1 (11-16-2016)

Documentation of Changes
INCORPORATED PLACES
Incorporated place

Type
PLACE
CODES

STATE
CODE

BAS ID

State

FIPS

ANSI

SPECIAL INSTRUCTIONS (If any)

Please follow the instructions below and review the preprinted entries for correctness and completeness and make changes as
necessary. For new legal changes, use the provided spaces to print the requested information requested for all annexations,
deannexations, and other changes that have occurred during the previous year(s).
Instructions for Entering Data in Columns
(1) Change – Enter A for annexations, D for deannexations, B for boundary corrections, or O for other changes.
(2) Authorization – Enter the authorization type. (O = Ordinance, R = Resolution, L = Local Law, S = State-level action, and X = Other)
(3) Authorization – Enter the authorization number for the change you are reporting.
(4) Date – Enter the effective date of the change. (Month, day, year)
(5) County/Equivalent – Enter the name of the county or equivalent area in which the change occurred.
(6) Minor Civil Division – Enter the name of the minor civil division (if any) in which the change occurred.
(7) Area – Enter the estimated size (in tenths of acres) of the annexation, deannexation or other change.

Authorization

Change
Type
A/D/O

Type
O/R/L/S/X

Authorization
Number

Date
Month/Day
Year

County/Equivalent
Name

Minor Civil Division
Name (if any)

Area
Acres
(Tenths)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

If additional space is needed, please use the BAS-1 "Documentation of Changes" form
found in the BAS Respondent Guide.
FORM BAS-1 (11-16-2016)

BAS-1

Documentation of Changes – Continued

FORM
(11-16-2016)

INCORPORATED PLACES
Incorporated place

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU

State

Type
PLACE
CODES

STATE
CODE

BAS ID

ANSI

FIPS

SPECIAL INSTRUCTIONS (If any)

Authorization

Change
Type
A/D/O

Type
O/R/L/S/X

Authorization
Number

(1)

(2)

(3)

Date
Month/Day,
Year

County/Equivalent
Name

Minor Civil Division
Name (if any)

Area
Acres
(Tenths)

(4)

(5)

(6)

(7)