Certification for Requested Tribal Data

OMB Approved No. 1505-0264

Expiration Date: 10/31/2020

Certification for Requested Tribal Data

Name of Indian Tribe:

_______________________________

Population: Total number of Indian Tribe Citizens/Members/Shareholders, as of January 1, 2020:

_______________________________

Land Base: Total number of land acres held by the Indian Tribe and any tribally-owned entity (to include entities in which the Indian Tribe maintains at least 51% ownership) as of January 1, 2020 (to include lands held in trust by the United States, owned in restricted fee status, owned in fee, or selected pursuant to the Alaska Native Claims Settlement Act).

_______________________________

Employees: Total number of persons employed by the Indian Tribe and any tribally-owned entity (to include entities in which the Indian Tribe maintains at least 51% ownership) on January 1, 2020.

_______________________________

Expenditures: Total expenditures for the most recently completed fiscal year.

_______________________________

CERTIFICATION

I hereby certify I am authorized by the governing body of the Indian Tribe described above to submit the information included with this form and that it is true and correct to the best of my knowledge. I further understand that anyone who knowingly and willfully makes a false statement to the United States Government may be subject to criminal prosecution under the False Statements Accountability Act of 1996, 18 U.S.C. 1001.

Name: _____________________________

Title: ______________________________

Date: ______________________________

Note: “Indian Tribe” means any Indian tribe, band, nation, or other organized group or community, including any Alaska Native village or regional or village corporation as defined in or established pursuant to the Alaska Native Claims Settlement Act (85 Stat. 688, 43 U.S.C. 1601 et seq.), which is recognized as eligible for the special programs and services provided by the United States to Indians because of their status as Indians.

PAPERWORK REDUCTION ACT NOTICE

The information collected will be used for the U.S. Government to process requests for support. The estimated burden associated with this collection of information is two hour per response. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be directed to the Office of Privacy, Transparency and Records, Department of the Treasury, 1500 Pennsylvania Ave., N.W., Washington, D.C. 20220. DO NOT send the form to this address. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid control number assigned by OMB.