Self-Certification of Appraiser Qualifications

OMB Control No. 1076-0188

Expiration Date: XX/XX/XXXX

U.S. Department of the Interior

Appraiser Qualifications

Appraisals & Valuations of Indian Property

Self-Certification

I certify that I meet the following qualifications to conduct an appraisal or valuation of Indian property:

(1) I hold a current Certified General Appraiser license in the State in which the property appraised or valued is located;

(2) I am in good standing with the appraiser regulatory agency of the State in which the property appraised or valued is located; and

(3) I am currently in compliance with, and will continue to comply with, the Uniform Standards of Professional Appraisal Practice (USPAP) rules and provisions applicable to appraisers (including but not limited to Competency requirements applicable to the type of property being appraised or valued and Ethics requirements). This includes competency in timber and mineral valuations if applicable to the subject property.

________________________________________ ____________________________

Name (printed) Licensing State and License No.

________________________________________ ____________________________

Signature Date

PRINCIPAL PURPOSE: This information is collected to ensure that appraisers conducting appraisals and valuations that will not be subject to Departmental review and approval are properly qualified.

EFFECT OF NOT PROVIDING THIS FORM: Submission of the form is required to obtain the benefit of waiving Departmental review and approval of the appraisal or valuation of Indian property. Failure to provide this form will subject the appraiser’s appraisal or valuation to Departmental review and approval.

AUTHORITY: The authority for collecting this information may be found at Public Law 114-178, Indian Trust Asset Reform Act.

PAPERWORK REDUCTION ACT NOTICE: The Paperwork Reduction Act of 1995 requires us to inform you that the Department of the Interior, or one of its bureaus or offices, collects the information requested on this form to ensure that you are qualified to conduct an appraisal or valuation of Indian property. The Department, bureau or office will review the certification to determine whether to conduct an independent Departmental review of the appraisal or valuation. This Information Collection has been approved by the Office of Management and Budget (OMB), and the currently valid OMB Control Number and Expiration Date appears on the upper right corner. No Federal agency may request or sponsor, and you are not required to respond to, a request for information which does not contain a currently valid OMB Control Number.

BURDEN HOURS STATEMENT: The public burden for this form is estimated at 1 hour per response including the time for reviewing instructions, gathering and maintaining data, and completing and reviewing the form. Direct comments regarding the burden estimate or any other aspect of this form to: Indian Affairs, Attn: RACA, Information Collection Clearance Officer, 1001 Indian School Road NW, Suite 229, Albuquerque, NM 87104. Note – comments, names and addresses of commentators are available for public review during regular business hours. If you wish us to withhold this information, you must state this prominently at the beginning of your comment. We will honor your request to the extent allowable by law.