OMB Control #1076-0153
Expiration Date: 03-31-2021
NOTICES AND CERTIFICATION
NOTICE OF APPEAL RIGHTS.
• When you receive your CDIB, you must review it for the correct name spelling, birth dates, and blood degrees. If you believe that
there are any mistakes on the CDIB, you must give a written request for corrections and provide supporting documentation to the
issuing officer within 45 days (60 for Alaska tribes) of the date on the letter. If you fail to meet this deadline, appeal rights will be
lost. If the issuing officer decides that corrections are not needed, he or she will send a written determination with an explanation
through certified mail to you and provide you with a copy of the appeals procedures.
• If you are denied a CDIB, you will be given a written determination with an explanation for the denial and a copy of the appeal
PAPERWORK REDUCTION ACT STATEMENT
The information collection requirement has been 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 1076-0153. The 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. Information is collected
when individuals seek certification that they possess sufficient Indian blood to receive Federal program services based upon their status
as American Indians or Alaska Natives. The information collected will be used to assist in determining eligibility of the individual to
receive Federal program services. The information is supplied by a respondent to obtain a Certificate of Degree of Indian or Alaska
Native Blood. It is estimated that responding to the request will take an average of 1.5 hours to complete. This includes the amount of
time it takes to gather the information and fill out the form. If you wish to make comments on the burden imposed by the form, please
send them to the Information Collection Clearance Officer, Office of the Assistant Secretary - Indian Affairs, 1849 C Street, NW,
Washington, DC 20240. DO NOT SUBMIT YOUR CDIB REQUEST TO THIS ADDRESS; you should instead submit your CDIB
request to the BIA Agency from whom you receive services. 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. In compliance with the Paperwork Reduction
Act of 1995, as amended, the collection has been reviewed by the Office of Management and Budget, and assigned a number and
expiration date. The number and expiration date are at the top right corner of the form.
PRIVACY ACT STATEMENT.
This information is collected pursuant to the Privacy Act, 5 U.S.C. 552a. Pursuant to system of record notice, Tribal Enrollment
Reporting and Payment System, Interior/BIA-7, the Bureau of Indian Affairs will not disclose any record containing such information
without the written consent of the respondent unless the requestor uses the information to perform assigned duties. The primary use of
this information is to certify that an individual possesses Indian blood to receive Federal program services. Examples of others who
may request the information are U.S. Department of Justice or in a proceeding before a court or adjudicative body; Federal, state, local,
or foreign law enforcement agency; Members of Congress; Department of Treasury to effect payment; a Federal agency for collecting a
debt; and other Federal agencies to detect and eliminate fraud.
NOTICE OF EFFECTS OF NON-DISCLOSURE.
Disclosure of the information on this CDIB request is voluntary. However, proof of Indian blood is required to receive Federal program
NOTICE OF STATEMENTS AND SUBMISSIONS.
Falsification or misrepresentation of information provided on this request is punishable under Federal Law, 18 U.S.C. 1001. Conviction
may result in a fine and/or imprisonment of not more than 5 years.
I request a CDIB, and certify that I have read the instructions, and above notices about my request for a CDIB. I further certify
that the information which I have provided with this request to the Bureau of Indian Affairs is true and correct.
(Requester’s signature) (date)
SUBMIT TO: BIA AGENCY FROM WHOM YOU RECEIVE SERVICES