Application to Share in Western Shoshone Funds as a Line

Page 3 of 10 OMB Control 1076-0165

Expiration Date: 06/30/2008

Please Read All Instructions Before Filling Out This Form - See Pages 5 through 9

APPLICATION TO SHARE IN WESTERN SHOSHONE FUNDS AS A LINEAL DESCENDANT OF THE WESTERN SHOSHONE IDENTIFIABLE GROUP

Pursuant to the Act of July 7, 2004, Pub. L. 108-270

All questions in this application must be answered.

This application is subject to the Privacy Act of 1974, Pub. L. 93-579

Application No.____________________ Date Received: ____________________

DO NOT WRITE ABOVE THIS LINE

A.

Last Name First Name (No Nicknames) Middle Name, Jr. Sr. Etc. Sex (Male / Female)

B.

Maiden, Alias, nicknames or other names used Social Security Number

C.

C/O (In care of)

D.

Address (Street No., Route No., Box No.) Telephone Number

E.

City State Zip Code

F.

Birthdate: mm/dd/yyyy Date of Death: mm/dd/yyyy (If applicant is deceased) Are you a United States citizen?

(yes or no)

Circle Yes or No to the following Questions:

G. Are you an adopted person? Yes No

H. Did you receive an earlier judgment fund per capita payment? Yes No

If you received a judgment fund per capita payment, state approximate year payment was received. __________

If you received a judgment fund per capita payment, which tribe or tribal group filed the claim? _____________

I. Are you enrolled member of a federally recognized tribe? Yes No

If enrolled, please name Tribe where enrolled ____________________________________________

__________________________________________________ ___________________________

Applicant's or Sponsor's Signature Date

J. Name and relationship of ancestor through whom you claim eligibility:

Last Name First and Middle Name Relationship

K.

Roll or document on which his or her name appears (See **Note** - Ancestry must be traced to ancestor named on one of the specified rolls).

Complete below if you are filing application on behalf of another person.

1.

Name of person completing this application Relationship to applicant

(Indicate whether parent, brother, sister, aunt, uncle, spouse, guardian, etc.)

2.

Mailing Address (If different from the address given for the applicant) Telephone Number

Applicant Certification to be filled out by all applicants or sponsors.

I certify that all the answers given are true, complete and correct to the best of my knowledge and belief, and they are made in good faith. This certification is made with the knowledge that the information will be used to determine eligibility to receive a judgment fund per capita payment pursuant the Act of July 7, 2004, Pub. L. 108-270, and that false or misleading statements may constitute a violation of 18 U.S.C. 1001, which provides a penalty for willfully making false or fraudulent statements in connection with any matter within the jurisdiction of any department or agency of the United States. This application contains material covered by the Privacy Act. No record will be communicated to anyone or any agency unless requested in writing, by the applicant, or unless an officer or employee of the tribal enrollment staff or other Federal agency requires it in the performance of their duties.

I certify the above-named, for whom this application is made, is the person or is a descendant by blood of the person through whom eligibility is claimed.

Signature of person filling out form Date

1. **Note** Complete ancestry chart on back of form to ancestor named on one of the Carson Agency or Western Shoshone Census Rolls, or other documentation acceptable to the Secretary that documents your Western Shoshone ancestry.

Control Number: _________________________

(The Control Number will be supplied by BIA and used for record tracking purposes)

Paperwork Reduction Act Statement

This information is being collected to determine the applicant's eligibility to receive a per capita payment from the Western Shoshone Identifiable Group Judgment Fund distribution. The information is supplied by a respondent to obtain a per capita share of the judgment funds. It is estimated that time necessary to prepare a response will vary widely depending upon the applicant’s age and family history. Individuals 50 years and older will probably spend an average of 1 hour per response, while those 30 years and younger and the non-enrolled tribal members may require 20 hours to prepare a 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 the Information Collection Clearance Officer, DAS-IRM/CIO, 625 Herndon Parkway, Herndon, Virginia 20170. Note: Comments, names and addresses of commenters 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. Please note that an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless there is a valid OMB clearance number.

Privacy Act Statement

The information being collected for the Western Shoshone Identifiable Group Enrollment Application process meets the requirements of the Act of July 7, 2004, Pub. L. 108-270., and is covered by a system of records which was published in the FEDERAL REGISTER on September 13, 1983, 48 FR 41102. The information collected will be used to determine an applicant's eligibility to share in the judgment fund per capita distribution to the Western Shoshone lineal descendants authorized under Pub. L. 108-270. The disclosure of this information is voluntary; however, failure to provide the information required to support the verification of ancestry may result in delay or the denial of the application to share in the distribution of the Western Shoshone judgment funds. To obtain further information about this system of records please contact the Tribal Enrollment Specialist, Division of Tribal Government Services, Bureau of Indian Affairs, 1849 C Street, N.W., Mail Stop 320-SIB, Washington, D.C. 20240

Instructions for Completing the Application Form

And the Family History Chart and Addendum

INSTRUCTIONS - Pages 1 & 2

Most of the required information on the application is self-explanatory. On lines where you might need additional clarification we have provided a brief explanation and/or type of information needed.

Line A. Enter applicant's complete name. Example: Use Joseph (if this is your given name) rather than Joe. Do not use nicknames.

Line B. Enter applicant’s previous married name(s). Example: 1 marriage) Jones;

2 marriage) Blackburn. If you have a nickname that you use, please provide it also. In the second part enter applicant's, social security number.

Line C. This line is primarily for use by parents or sponsors who are filing applications for others whose correspondence should be addressed in care of the parent or sponsor.

Line D. Self-explanatory.

Line E. Self-explanatory.

Line F. The applicant’s date of birth must be provided. A copy of a state certified birth certificate that shows both parents’ names and the mother’s maiden name will substantiate the applicant’s birth date, parentage and citizenship. If a state certified birth certificate does not exist or is unavailable, any of the following documents may be provided: copies of baptismal records, probate findings, census records, Bureau of Indian Affairs records and affidavits. It is necessary that acceptable proof, as indicated above, be furnished. It is not necessary to secure proof of birth for those individuals listed on the BIA census rolls prepared in the 1940s and earlier.

Proof of Paternity must be provided if the applicant was born out of wedlock and the Western Shoshone ancestry is derived through the father. A copy of a court order determining paternity or a notarized statement signed by the father claiming paternity is sufficient documentation. If the father is deceased, an affidavit from the father’s parents, siblings or spouse stating that the father acknowledged paternity of the child during the father’s lifetime

Date of Death: Attach a copy of the death certificate for the deceased applicant. This pertains to applicants who were living on July 7, 2004, but who have died since that date.

Citizenship: Indicate if you are a citizen of the United States. If you are a U.S. citizen, but were born outside of the United States, provide us with a copy of one of the following three documents: 1/ Consular Report of Birth Abroad (Form FS-240), 2/ Certification of Report of Birth (DS-1350), or 3/ Certificate of Citizenship. The first two documents are issued by the Department of State. The third document is issued by the Immigration and Naturalization Service. Information concerning these documents and how to obtain or replace them can be found on the Internet at http://travel.state.gov/family/issues_birth.html.

Line G. If adopted, attach documentation (birth certificate at birth, adoption decree and amended birth certificate) which discloses the names of biological/natural parent(s).

Line H. Did you share in any other judgment fund per capita distribution? If so, identify the award and the approximate date of payment. We will review the award to determine the type of claim the award was based upon.

Line I. If you are enrolled with a federally recognized tribe, please indicate yes, and list the tribe’s name. This information is necessary in the event the funds are deposited into a restricted Individual Indian Money (IIM) account.

Line J. Give name and relationship of ancestor through whom you claim to be a descendant by blood.

Line K. Ancestry must be traced to an ancestor named on one of the Carson or Western Shoshone Agency rolls, or other documents acceptable to the Secretary that establishes your Western Shoshone ancestry

EXAMPLE:

Doe, John, G‑Grandfather No. 001 – 1940 Census Roll, Carson Agency, Non-Reservation Shoshone Area (Northeastern Nevada)

IT IS VERY IMPORTANT FOR YOU TO PROVIDE THE INFORMATION REQUIRED FOR THIS FIELD.

If your ancestor's name is not known, please state it. Every effort will be made to assist you in establishing eligibility and an attempt will be made to identify your ancestor from the information you provide on the family history chart. COMPLETE THE FAMILY HISTORY CHART WITH AS MUCH INFORMATION AS YOU CAN.

Family History Charts

Definitions - Use Codes:

BD = Birth date. Enter the dates using the "mm/dd/yyyy" format.

DOD = Date of Death. Enter the dates using the "mm/dd/yyyy" format.

BR = Base Roll Number. Enter the base roll number if the applicant or any of the applicant's ancestors are/were enrolled with a federally recognized tribe and their name appears on the tribe's base roll.

NI = Non-Indian. Enter NI for all named ancestors that are non-Indian.

NEWSLD = Not Enrolled Western Shoshone Lineal Descendant. Enter NEWSLD if the applicant or the applicant's ancestors have Western Shoshone blood, but they are/were not enrolled with any federally recognized tribe.

EWOT = Enrolled With Other Tribe. Enter EWOT if the applicant or the applicant's ancestors are enrolled with another federally recognized tribe. Do not include Bishop Shoshone Tribe, Duckwater Shoshone Tribe, Duck Valley Shoshone Tribe, Ely Shoshone Tribe, Fallon Shoshone Tribe, Fort McDermitt Shoshone Tribe, Yomba Shoshone Tribe, Timbisha Shoshone Tribe, or the Te-Moak Tribe of Western Shoshone in this category.

BST = Bishop Shoshone Tribe. Enter BST if the applicant or the applicant's ancestors are/were enrolled with the Paiute-Shoshone Indians of the Bishop Community of the Bishop Colony, California.

DST = Duckwater Shoshone Tribe. Enter DST if the applicant or the applicant's ancestors are/were enrolled with the Duckwater Shoshone Tribe of the Duckwater Reservation, Nevada

DVST = Duck Valley Shoshone Tribe. Enter if the applicant or the applicant's ancestors are/were enrolled with the Shoshone-Paiute Tribes of the Duck Valley Reservation, Nevada.

EST = Ely Shoshone Tribe. Enter if the applicant or the applicant's ancestors are/were enrolled with the Ely Shoshone Tribe of Nevada.

FST = Fallon Shoshone Tribe. Enter if the applicant or the applicant's ancestors are/were enrolled with the Paiute-Shoshone Tribes of the Fallon Reservation and Colony, Nevada.

FMST = Fort McDermitt Shoshone Tribe. Enter if the applicant or the applicant's ancestors are/were enrolled with the Fort McDermitt Paiute and Shoshone Tribes of the Fort McDermitt Indian Reservation, Nevada and Oregon.

YST = Yomba Shoshone Tribe. Enter if the applicant or the applicant's ancestors are/were enrolled with the Yomba Shoshone Tribe of the Yomba Reservation, Nevada.

TST = Timbisha Shoshone Tribe. Enter if the applicant or the applicant's ancestors are/were enrolled with the Death Valley Timbi-Sha Shoshone Band of California.

TTWS = Te-Moak Tribe of Western Shoshone. Enter if the applicant or the applicant’s ancestors are/were enrolled with the Te-Moak Tribe of Western Shoshone Indians of Nevada

Instructions for completing pages 3 & 4 of this application

(I) Enter your name (or the applicant's name if you are filing the application on behalf of someone else), the date of birth, if deceased, the applicant's date of death, tribal affiliation(s), and, if known, tribal roll number. ¹

(II) Enter the names of the applicant's parents, dates of birth, if deceased, dates of death, tribal affiliation(s), and if known, tribal roll number.

(III) Enter the names of the applicant's Indian grandparents, dates of birth, dates of death, tribal affiliation(s), and if known, tribal roll number.

(IV) Enter the names of the applicant's Indian great-grandparents, dates of birth, dates of death, tribal affiliation(s), and if known, tribal roll number.

Addendum - Family History Charts (Great-grandfather or Great-grandmother)

(V) Please duplicate a sufficient number of this form so you can use one form for each of the applicant's Indian great-grandfather and great-grandmother named under IV on the first page of the Family History Chart. Re-enter the name(s) listed under IV, date of birth, date of death, tribal affiliation(s), and if known, tribal roll number.

(VI) Enter the names of the applicant's Indian great-great-grandparents, dates of birth, dates of death, tribal affiliation(s), and if known, tribal roll number.

(VII) Enter the names of the applicant's Indian great-great-great-grandparents, dates of birth, dates of death, tribal affiliation(s), and if known, tribal roll number.

(VIII) Enter the names of the applicant's Indian great-great-great-great-grandparents, dates of birth, dates of death, tribal affiliation(s), and if known, tribal roll number.

Mailing Instructions Please mail the following documents to:

Tribal Government Services

BIA-Western Shoshone

P.O. Box 3838

Phoenix, AZ 85030-3838

1. The application and the family history charts. (Pages 1 - 4 of the application)

2. State certified birth certificates for the applicant. A copy of a state certified birth certificate that shows both parents names and the mother’s maiden name will substantiate the applicant’s birth date and parentage. If a state birth certificate does not exist or is unavailable, any of the following documents may be provided: copies of baptismal records, probate findings, census records, Bureau of Indian Affairs records and affidavits. It is necessary that acceptable proof, as indicated above, be furnished. It is not necessary to secure proof of birth for all persons listed on the family tree, except in those cases where we are totally unable to document ancestry through records already on file with the Bureau of Indian Affairs.

3. Proof of paternity must be provided if the applicant was born out of wedlock and the Western Shoshone ancestry is derived through the father. A copy of a court order determining paternity or a notarized statement signed by the father acknowledging paternity is sufficient documentation. If the father is deceased, an affidavit from the father’s parents, siblings or spouse stating that the father acknowledged paternity of the child during the father’s lifetime is sufficient.

4. Attach a copy of the death certificate for the deceased applicant. This pertains to applicants who were living on July 7, 2004, but who have died since that date.

5. If you are a U.S. citizen, but were born outside of the United States, provide us with a copy of one of the following three documents: 1/ Consular Report of Birth Abroad (Form FS-240), 2/ Certification of Report of Birth (Form DS-1350), or 3/ Certificate of Citizenship. The first two documents are issued by the Department of State, the third document is issued by the Immigration and Naturalization Service.

6. Death Certificates for applicant, if applicable. Copies of probate records are acceptable in lieu of a death certificate.

7. If possible, please make every effort to mail all family applications in the same envelope. This will help to speed the review process by letting us group the applications by family groups. It will also help reduce the cost of duplication for the required birth certificate / death certificate documentation.

8. Make sure that the application is signed and dated on pages 1 and 2.

1 Please use the codes listed on the upper left-hand corner of the family history chart to identify tribal affiliation/tribal enrollment status for each ancestor listed. The definitions for those codes are listed on pages 7 and 8 of this document.

Mail To: Tribal Government Services, BIA-Western Shoshone, P.O. Box 3838, Phoenix, Arizona 85030-3838