BLM Form AK2569-010

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Form AK 2569-10
(Nov. 2020)

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FORM APPROVED
OMB NO. 1004-0216
Expires: July 31, 2026

UNITED STATES
DEPARTMENT OF THE INTERIOR
BUREAU OF LAND MANAGEMENT

BLM Land Office

ALASKA NATIVE VIETNAM-ERA VETERAN LAND
ALLOTMENT APPLICATION

BLM Serial Number

ACT OF MARCH 12, 2019. PUBLIC LAW 116-9, SEC. 1119
Type or print plainly in ink and sign in ink
1. Name Eligible Individual:

(First Name)

(Middle Name)

(Last Name)

Fill in 2 only if you are a Personal Representative of a deceased Eligible Individual or a Guardian/Conservator or have Power of Attorney of the living
Eligible Individual
2. Name of person filing application:

(First Name)

(Middle Name)

(Last Name)

Please check the appropriate relationship to the Eligible Individual:
Personal Representative

Guardian

Conservator

Power of Attorney

3. Mailing Address:

City:

State:

4. Date of Birth of Eligible Individual:

month

day

Zip Code:
year

5. Telephone number including area code of person filing application (optional):

6. You must submit a map with your application to show where your claimed allotment is located. Use a topographic map or a similar quality map. Please
provide the following information pertaining to the lands you have selected. If you need help, contact BIA at 1-800-645-8465, your BIA Service Provider
or on the web at: www.blm.gov/ak-native-vietnam-vet-land-allotment-2019.
Sec(s).

, Township

North/South, Range

East/West, Meridian

. Acres

.

Sec(s).

, Township

North/South, Range

East/West, Meridian

. Acres

.

Map attached

Yes

No

.

Other descriptive details:
7. Eligible Individual: I meet [the deceased meets] the qualifications listed in 43 U.S.C. §1629g-1(a)(2)
a. I am [the deceased was] an Alaska Native as defined in section 3(b) of the Alaska Native Claims Settlement Act (43 U.S.C. 1602(b))
Yes

No

.

b. I am [the deceased was] a Veteran as defined in section 101 of title 38, United States Code
Yes
No
.
c. I [the deceased] served at some point during the time from August 5, 1964 and December 31, 1971
Yes
No
.
d. Do you [Does the deceased] have an active application or have you/the deceased received a conveyance of land in your/their own right pursuant to:
A. the Act of May 17, 1906 (34 Stat. 197, chapter 2469) (as in effect on December 17, 1971)
.
Yes
No
B. section 14(h)(5) of the Alaska Native Claims Settlement Act (43 U.S.C. 1613(h)(5)); or
Yes
No
.
C. section 41 of the Alaska Native Claims Settlement Act (43 U.S.C. 1629g).
Yes
No
.
If lands were inherited lands pursuant to any of the above listed Acts, you are still eligible to apply under this Act.
(Continued on Page 2)

(AK 2569-10 December 2023, Page 1)

8. You are required to provide proof of the Eligible Individual’s qualifying military service. (e.g. Form DD-214 or other official documentation)
Document attached

Yes

No

.

9. You are required to provide proof that the Eligible Individual is an Alaska Native. (e.g. Certificate of Degree of Indian Blood or other official
documentation)
Document attached

Yes

No

.

10. If the Eligible Individual is deceased, you are required to provide proof of a current appointment as personal representative of the estate of the
deceased Eligible Individual by the proper Alaska State court.
Document attached
Not applicable

Yes

No

.

11. If you are a guardian/conservator or have power of attorney, you are required to provide proof of a current appointment as such by the proper Alaska
State court.
Document attached
Not applicable

Yes

No

.

I CERTIFY that the statements made herein are true, complete and correct to the best of my knowledge and belief and are made in good faith.
I understand that providing false statements is a criminal offense and I can be prosecuted pursuant to 18 U.S. Code section 1001.
(Date)

(Signature, mark or thumb print of applicant)

(Date) (Signature of witness) Two witnesses must sign only if applicant endorses application with his mark or thumb print rather than by signature

(Date) (Signature of witness) Two witnesses must sign only if applicant endorses application with his mark or thumb print rather than by signature

All supporting documents must be filed with the application. Any missing documentation may result in the rejection of your application. An
application will not be determined accepted until the application is complete.
Paperwork Reduction Act Statement:
The Paperwork Reduction Act of 1995 requires us to inform you that:
BLM will use the information to determine whether or not to issue an Alaska Native Vietnam Era Land Allotment.
Response to this request is required to obtain a benefit.
BLM would like you to know that you do not have to respond to this or any other Federal agency-sponsored information collection unless it
displays a currently valid OMB control number.
Public reporting burden for this form is estimated to average 28 hours per response, including the time for reviewing the instructions,
gathering and maintaining the data, and completing and reviewing the form. Direct comments concerning the burden estimate or any other
aspect of this form to: U.S. Department of the Interior, Bureau of Land Management, Bureau Clearance Office (HQ-630), (AK-2569-10040216), Mail Stop 2134 LM, 1849 C Street, NW Washington D.C. 20240.
Privacy Act Statement:
The Privacy Act of 1974 and the regulations at 43 CFR 2.48(d) provide that you be furnished with the following information:
AUTHORITY: Public Law 116-9, Sec. 1119, 43 U.S.C. 1629g-1
PRINCIPAL PURPOSE: BLM will use the information you provide to process your application and determine if you are eligible to receive an
allotment under the Alaska Native Veterans Allotment Program of 2019.
ROUTINE USES: BLM will disclose the information according to the release information contained in the regulations at 43 CFR 2.56(d).
EFFECT OF NOT PROVIDING THE INFORMATION: Disclosing the information is necessary to receive a benefit. Not disclosing the
information may result in BLM rejecting your application.
For additional information, please get information through BLM Alaska’s website at: www.blm.gov/ak-native-vietnam-vet-land-allotment-2019

(AK 2569-10 December 2023, Page 2)