Tribal Enrollment Data Collection

OMB Control No. 1076-0197
Expires XX/XX/XXXX

United States Department of the Interior
OFFICE OF THE SECRETARY
Washington, DC 20240

TRIBAL ENROLLMENT DATA COLLECTION
This is a request for updated Tribal enrollment information. This Tribal enrollment information
will be consolidated at the headquarters offices in Washington, DC and used by Indian Affairs
(IA) to support decisions regarding the allocation of funds and services to tribes. IA may also
provide the information to other Federal agencies for their use in making fund distributions.
(Please insert requested information & sign below)

DRAFT

-- Choose Tribe -Tribe Name: ______________________________________________________________

Tribal Enrollment Number: _________________ as of Month Day, 20XX
(Please check box for concurrence)

I have read the above disclaimer and agree to the use of this information for these
purposes. Further, I hereby certify I am authorized by the governing body of the Tribe named
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.

______________________________________________
Signature

_____________
Date

_________________________________________________________________
Printed Name & Title of Tribal Leader
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. The valid OMB control number for this collection is 1076-0197.
The time to complete this information collection request is estimated to average 1 hour per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining data needed, and completing and reviewing the collection of
information. Responses to this collection of information are voluntary (25 U.S.C. § 2). If you have comments on the agency's need for this
information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, including through
the use of automated collection techniques, please send those comments to the Indian Affairs Information Collection Clearance Officer by email
at [email protected] or by mail to 1001 Indian School Road NW, Suite 229, Albuquerque, NM 87104. Please include the OMB control number
in any correspondence. Do not send the completed form to this address; see the instructions accompanying this form for where to send your
completed form.