BAS-5 BAS 5 - AIA Form

BAS-5

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)
AMERICAN INDIAN RESERVATIONS AND OFF-RESERVATION TRUST LAND
Boundaries as of —

GENERAL
INSTRUCTIONS

To report changes for your American Indian Area (AIA), please complete this form.
• 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 1–800–796–3748, 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.

American Indian reservation/off-reservation trust land name
CENSUS
CODE

BAS ID
Question 1

ANSI

CODE

NAME CHANGE – Please mark (X) the applicable boxes.

1a. Is the name of this American Indian reservation/off-reservation trust land correct as shown above?
Please provide supporting documentation:
(Refer to the BAS Respondent Guide for instructions.)

Yes – Continue with question 2.
No – Enter correction here.
Continue with question 2.
Question 2
Mailing
Address

Name

Effective date of change
Date (Month/Day/Year)

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

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

Name
Address
Position
Department

City

Telephone

(

)

Fax

(

)

Ext.

State
E-mail

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

Question 3
Mailing
Address

ZIP code

Mark (X) this box if the BAS Respondent
is the same as the Tribal Chair.

CONTACT INFORMATION – Please fill in or correct the contact information below.

BAS Mailing Contact
(Provide address where BAS materials should be sent.)

Name
Address
Position
Department

City

Telephone

(

)

Fax

(

)

Mailing Address

Ext.

State

ZIP code

E-mail

Tribal Chair

Name
Address
Position
Department

City

Telephone

(

)

Fax

(

)

Ext.

State

ZIP code

E-mail

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.

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

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

Thank you for your participation and timely response.

QUESTIONS?
For further information:
Telephone:
E-mail:

[email protected]

Website:

https://www.census.gov/programs-surveys/bas.html

SPECIAL INSTRUCTIONS (If any)
*If you have tribal subdivision changes, please return your paper forms.

Please check appropriate box.
Tribal Governing Body Type:
Federal
Traditional
Self-Governance
Other

IMPORTANT – PLEASE REVIEW THE ENCLOSED MAPS AND ANNOTATE EACH CHANGE ON THE MAP(S)
WITH THE APPROPRIATE DOCUMENTATION ACCORDING TO THE INSTRUCTIONS PROVIDED IN THE
BAS RESPONDENT GUIDE.
Update the map(s) USING THE APPROPRIATE COLORED PENCILS.
You must provide supporting documentation such as a trust deed or court order when submitting legal
boundary changes.

CENSUS USE ONLY
Date processed

Clerk ID processed

S/S change

Map received

Map
change

Date verified

Clerk ID verified

S/S no
change

Other map

Map no
change

Date form keyed

Date GPP updated

PLAT/
Description

Map
signed

Letter

FORM BAS-5 (11-17-2016)

BAS-5

FORM
(11-17-2016)

Question 4

LEGAL BOUNDARY AND OTHER CHANGES – Please mark (X) the applicable box(es).

Time period
4a. Were there any additions or deletions of any reservation or off-reservation trust land areas during the time period shown above?
(Include legal changes such as changing the status of land from off-reservation trust land to reservation land. Please refer to the
BAS Respondent Guide for a description of legal boundary changes.)
Yes – Record all legal changes (additions, deletions and other changes) in the Documentation of Changes section of the
form and update the map(s) USING THE ENCLOSED RED PENCIL.
Provide supporting documentation for each change (i.e. trust deed or court order). Continue with question 4b.
No – Continue with question 4b.
4b. Were there any additions or deletions of any reservation or off-reservation trust land areas before the time period shown above
that do not appear on the enclosed maps?
(Include legal changes such as changing the status of land from off-reservation trust land to reservation land.)
Yes – Record all legal changes (additions, deletions and other changes) in the Documentation of Changes section of
the form and update the map(s) USING THE ENCLOSED RED PENCIL. Provide supporting documentation for
each change (i.e. trust deed or court order). Continue with question 4c.
No – Continue with question 4c.
4c. 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 initials BC to indicate a boundary correction.
Enter the total number of boundary corrections.

Continue with question 4d.

No – Continue with question 4d.
4d. Did you add, delete, or modify any tribal subdivision areas?
(Include changes to name, type and/or status as well as boundary changes.)
Yes – Complete the Tribal Names and Status Documentation Section of the form. Continue with question 4e.
No – Continue with question 4e.
4e. Did you change, add or delete any roads, streams/rivers, or any other physical features on the map(s)?
Yes – Correct the map(s) according to the instructions provided in the BAS Respondent Guide. Continue with question 4f.
No – Continue with question 4f.
4f. Did you change, add or delete any of the address ranges shown at the reservation and/or off-reservation trust land
boundary, or add any address ranges for boundary changes you made to the map(s)?
Yes – Correct the map(s) according to the instructions provided in the BAS Respondent Guide.
No

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

For further information: https://www.census.gov/programs-surveys/bas.html

Documentation of Changes
AMERICAN INDIAN RESERVATIONS AND OFF-RESERVATION TRUST LAND
American Indian reservation/off-reservation trust land name
CENSUS
CODE

BAS ID

CODE

ANSI

Please follow the instructions below and review the preprinted entries for correctness and completeness. Print in the space provided the
information requested for all additions, deletions and other changes that have occurred during the previous year.
Instructions for Entering Data in Columns
(1) Change – Enter A for additions, D for deletions, B for boundary corrections, or O for other changes.
(2) Authorization (Type) – Enter the authorization type. (A = Act of Congress, Statute, or Federal Law. C = Federal Court decision,
D = Deed placing land into trust, and N = Federal Register notice or notice published in a local newspaper by the federal
government, or X = Other)
(3) Authorization (Identifying Number) – Enter the identifying number for the change you are reporting.
(4) Date – Enter the effective date of the change. (Month, day, year)
(5) Land – Enter the type of land added. (R = reservation or T = off-reservation trust land)
(6) County/Equivalent – Enter the name of the county or equivalent area in which the change occurred.
(7) Area – Enter the estimated size (in tenths of acres) of the addition, deletion or other change.

Change
Type
A/D/B/O
(1)

Authorization
Type
A/C/D/N/X
(2)

Identifying Number
(If any)

Date
Month/Day
Year

Land
Type
R/T

County/Equivalent
Name

Area
Acres
(Tenths)

(3)

(4)

(5)

(6)

(7)

If additional space is needed, please use the BAS-5 "Documentation of Changes" form
found in the BAS Respondent Guide.
FORM BAS-5 (11-17-2016)

Documentation of Changes – Continued
AMERICAN INDIAN RESERVATIONS AND OFF-RESERVATION TRUST LAND
American Indian reservation/off-reservation trust land name
CENSUS
CODE

BAS ID
Change
Type
A/D/B/O
(1)

Authorization
Type
A/C/D/N/X
(2)

FORM BAS-5 (11-16-2016)

Identifying Number
(If any)
(3)

CODE

ANSI

Date
Month/Day,
Year

Land
Type
R/T

County/Equivalent
Name

Area
Acres
(tenths)

(4)

(5)

(6)

(7)

Tribal Names and Status Documentation
TRIBAL SUBDIVISIONS
American Indian reservation/off-reservation trust land name
CENSUS
CODE

BAS ID

CODE

ANSI

Tribal Subdivisions as of
Listed below are all of the tribal subdivisions in the U.S. Census Bureau records that have been submitted by your tribal
government for your reservation and/or off-reservation trust land. Tribal subdivisions are units of self-government or
administration within reservation and/or trust land boundaries that serve social, economic, cultural, or legal purposes and may be
designated as districts, communities, chapters, precincts, etc.
If your tribal government previously submitted tribal subdivisions to the U.S. Census Bureau, please review the list of tribal
subdivisions below and make any necessary changes to the name, type, status or date. Active, legal subdivisions are defined as
having a functioning government with elected officials that provides services within the subdivision. Inactive subdivisions have no
functioning government or elected officials and receive services solely from the tribe. Tribal government resolutions or ordinances
must accompany any changes as supporting documentation. If you would like to delineate a tribal subdivision for the first time,
please refer to the BAS Respondent Guide for instructions.
To report additions, deletions, modifications and/or boundary changes to existing tribal subdivisions, please update both the list
below and the enclosed map(s). You may make changes to the maps with the BLUE pencil that is provided. Please refer to your
BAS Respondent Guide for more information.

(2)

Boundary
correction

the type shown is incorrect —
Please draw a line through it,
Print the correct type above it, and
Enter the date the change was
effective in column (8). if applicable.

Legal
boundary
change

If
•
•
•

Subdivision
never
existed

Is this an active [A] or inactive [I]
subdivision? (See definitions above.)

STATUS CHANGES
If changes in status have occurred:
mark (X) the appropriate column
and enter the effective date in
EFFECTIVE
column (8).
DATE
Deleted
subdivision

(1)

TYPE

New
subdivision

OFFICIAL NAME OF TRIBAL
SUBDIVISION
If the name shown has changed —
• Please draw a line through it,
• Print the correct name above it, and
• Enter the date the change was effective
in column (8).
If the name is misspelled —
• Please correct the spelling only.
• Do not enter a date in column (8).

(3)

(4)

(5)

(6)

(7)

Month, day,
year

If additional space is needed, please use the BAS-5 "Tribal Names and Status Documentation" form
found in the BAS Respondent Guide.
FORM BAS-5 (11-16-2016)

(8)

Tribal Names and Status Documentation – Continued
TRIBAL SUBDIVISIONS
American Indian reservation/off-reservation trust land name
CENSUS
CODE

FORM BAS-5 (11-16-2016)

the type shown is incorrect —
Please draw a line through it,
Print the correct type above it, and
Enter the date the change was
effective in column (8). if applicable
(2)

Boundary
correction

If
•
•
•

Legal
boundary
change

Is this an active [A] or inactive [I]
subdivision? (See definitions above.)

STATUS CHANGES
If changes in status have occurred
mark (X) the appropriate column
and enter the effective date in
column (8).
Subddivision
never
existed

(1)

TYPE

ANSI

Deleted
subdivision

OFFICIAL NAME OF TRIBAL
SUBDIVISION
If the name shown has changed —
• Please draw a line through it,
• Print the correct name above it, and
• Enter the date the change was effective
in column (8).
If the name is misspelled —
• Please correct the spelling only.
• Do not enter a date in column (8).

CODE

New
subdivision

BAS ID

(3)

(4)

(5)

(6)

(7)

EFFECTIVE
DATE
Month, day,
year

(8)