(Attachment to Family History Chart

OMB Control # 1076-0160

Expiration Date:XX/XX/XXXX

Family History Chart

For Categories B, C & D

			(IV) Great-grandfather BD:_____________ Tribe:
		(III) Grandfather BD:_____________ Tribe:
			(IV) Great-grandmother BD:_____________ Tribe:
	(II) Father BD:_____________ Tribe:
			(IV) Great-grandfather BD:_____________ Tribe:
		(III) Grandmother BD:_____________ Tribe:
			(IV) Great-grandmother BD:_____________ Tribe:
(I) Applicant BD:_____________ DOB:_____________ Tribe:
			(IV) Great-grandfather BD:_____________ Tribe:
		(III) Grandfather BD:_____________ Tribe:
			(IV) Great-grandmother BD:_____________ Tribe:
	(II) Mother BD:_____________ Tribe:
			(IV) Great-grandfather BD:_____________ Tribe:
		(III) Grandmother BD:_____________ Tribe:
			(IV) Great-grandmother BD:_____________ Tribe:

PAPERWORK REDUCTION ACT NOTICE:

The information collection is approved by the Office of Management and Budget under the Paperwork Reduction Act of 1995, 44 U.S.C. 3507(d), and assigned clearance number 1076-0160. This information is collected to verify that individuals are eligible for preference when appointments are made to vacancies in positions in the Bureau of Indian Affairs. It is estimated that it takes the applicant about 30 minutes to complete this form. A Federal 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. If you have any questions regarding the burden estimation, please contact: Information Collection Clearance Officer – Indian Affairs, 1001 Indian School Road NW, Suite 229, Albuquerque, NM 87104.

PRIVACY ACT STATEMENT:

This information is collected as provided pursuant to the Privacy Act, 5 U.S.C. 552a, for individuals completing application forms for Federal employment with the Bureau of Indian Affairs (DOI) or the Indian Health Service (DHHS). We are authorized to collect information to verify Indian ancestry or Indian tribal membership by 25 U.S.C. 2, 4 Stat. 564 and 15 Stat. 228; 25 U.S.C. 9, 4 Stat. 738; 25 U.S.C. 43; 36 Stat. 272; 25 U.S.C. 44, 28 Stat. 313; 25 U.S.C. 46, 22 Stat. 88 and 23 Stat. 697; 25 U.S.C. § 348, 24 Stat. 398 and 31 Stat. 1085; 25 U.S.C. 472, 48 Stat. 986; 25 U.S.C. § 472a, 93 Stat. 1057 and 94 Stat. 695; 25 U.S.C. 479, 48 Stat. 988; and 5 U.S.C. 8336. The information collected will be used to determine eligibility for Indian preference and may be disclosed to the Department of the Interior Office of Personnel, the United States Office of Personnel Management, and the Indian Health Services Office of Personnel. The system of records notice is OPM/GOVT-1, General Personnel Records, 77 FR 73694 (December 11, 2012).