Form and Instruction

OMB Control No. 1076-0183

Expires: XX/XX/XXXX

SECRETARIAL ELECTION

VOTER REGISTRATION FORM

Last Name	First Name	Middle Name			Jr/Sr/III
Address where you live
City		State		Zip Code
Address where you get your mail (if mail is not delivered to your home)			Date of Birth

• 

  I hereby certify that I am a member of the [BIA - INSERT TRIBE NAME] and that I am at least 18 years of age or will be at least 18 years of age on the date of the Secretarial Election ([BIA – INSERT ELECTION DATE]).

  
  

  
  

  Signature (must sign to be valid) (Date)

  Completing and returning this registration is necessary if you desire to vote in the forthcoming Secretarial election;

• This form, upon completion and return to the Secretarial Election Board, will be the basis for determining whether your name will be placed upon the list of registered voters, and therefore may receive a ballot;

• Completion and return of this form is voluntary, but failure to do so will prevent you from participating in the Secretarial election;

• Print your name and address;

• Sign your name and date; and

• Return this Voter Registration Form in the pre-addressed envelope provided.

PRIVACY ACT STATEMENT

25 CFR Part 81 authorizes the collection of this information. The information is confidential and is never disclosed without written clearance and consent of the applicant. The primary use of this information is to determine an Indian individual’s eligibility to vote in a Secretarial election. Additional disclosures of this information may be to other BIA or tribal officials in the conduct of their official duties pertaining to the preparation for and conduct of a Secretarial election, or in the conduct of program review and to the Office of Inspector General or the General Accounting Office when conducting an audit of BIA Programs, or local Law Enforcement agency when the agency becomes aware of violation or possible violation of civil or criminal law, and to the General Services Administration in connection with its responsibility for records management. This information will be entered into the BIA, Tribal Rolls, Interior/BIA-7 (76 FR 59733), which can be obtained upon request from the Chief, Division of Tribal Government Services, 1849 C Street, N.W., MS-3645-MIB, Washington DC 20240. No record contained therein may be disclosed by any means of communication to any person, or to another agency, except pursuant to a written request by, or with prior written consent of the individual to whom the record pertain.

Under the Privacy Act, BIA may not give out your information except that BIA may share the information with other Federal, State, and Tribal offices and programs that have a responsibility to facilitate the Secretarial election. The information can also be given to those agencies for law enforcement purposes. This can be done without your consent. For any other person or program wanting information from your case file, you must first give your written consent. You have the right to know what records exist on you and you can ask to see them. If you believe some information in on you is inaccurate, you may contact the Chief, Division of Tribal Government Services, to request a correction.

PAPERWORK REDUCTION ACT STATEMENT

This information is being collected to determine eligibility for voting in a Secretarial election. Response to this collection is required to obtain benefits under 25 CFR 81. 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. Public reporting for this form is estimated to average 15 minutes per response, including the time for reviewing instructions, gathering and maintaining data, completing the form. Direct comment regarding the burden estimate or any other aspect of this form to: Information Collection Clearance Officer, Office of Regulatory Affairs & Collaborative Action – Indian Affairs, 1001 Indian School Road NW, Suite 229, Albuquerque, NM 87104.