BASSC State Certifying Official Sign-Up Form

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:
Name:

ST
YYYY

Title:
Department:
Address:
City:

State:

Telephone:

Email:

Zip Code:

State Certification Materials will be emailed 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: __________________________________________________
Please email, fax, or mail this
completed form to the
U.S. Census Bureau:

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

Date:

__________________

Email Address: [email protected]
Fax Number: 1-800-972-5652

If you have not yet done so, please respond to [email protected] with a summary of your state laws
regarding
annexations, deannexations, incorporations and disincorporations. These state law summaries are available
on the BAS website for the BAS State Certification Program.
A list of annexations received through the BAS program is available online at: https://www.census.gov/
geographies/reference-files/time-series/geo/bas/annex.html
Please see the back of this form/letter for additional information.

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.