Form 8304 Individual History Chart

BIA-8304 OMB No. 1076-0104 Expires 04/30/2010

INDIVIDUAL HISTORY CHART

(To be completed by each adult member of the group)

MEMBER’S NAME:____________________________________________________________________

NAME OF MEMBER’S WIFE/HUSBAND: (If wife, give name before marriage)

_____________________________________________________________________

NAMES OF MEMBER’S CHILDREN: (Indicate whether child is male or female)

1 __________________________________________________________________________

2 __________________________________________________________________________

3 __________________________________________________________________________

4 __________________________________________________________________________

5 __________________________________________________________________________

6 __________________________________________________________________________

7 __________________________________________________________________________

8 __________________________________________________________________________

9 __________________________________________________________________________

10 _________________________________________________________________________

NAME OF MEMBER’S FATHER: __________________________________________________________

NAME OF MEMBER’S MOTHER: (Give name before marriage)

______________________________________________________________________

NAMES OF MEMBER’S BROTHERS:

1 __________________________________________________________________________

2 __________________________________________________________________________

3 __________________________________________________________________________

4 __________________________________________________________________________

5 __________________________________________________________________________

6 __________________________________________________________________________

7 __________________________________________________________________________

8 __________________________________________________________________________

9 __________________________________________________________________________

10 _________________________________________________________________________

NAMES OF MEMBER’S SISTERS:

1 __________________________________________________________________________

2 __________________________________________________________________________

3 __________________________________________________________________________

4 __________________________________________________________________________

5 __________________________________________________________________________

6 __________________________________________________________________________

7 __________________________________________________________________________

8 __________________________________________________________________________

9 __________________________________________________________________________

10 _________________________________________________________________________

_____________________________________________________ _______________

(Name of person preparing this chart if not a member of the group) (Date prepared)

Paperwork Reduction Act Statement: This information is collected to meet the mandatory criteria for acknowledgment set out in 25 CFR 83. The information is supplied by a respondent to obtain a benefit, Federal acknowledgment as an Indian tribe. It is estimated that responding to the request will take an average of 2 minutes 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 form, please send them to the Information Collection Control Officer, Office of Regulatory Affairs - Indian Affairs, 1849 C Street, NW, MS 4141, Washington, DC 20240. Comments, including names and addresses of respondents, will be available for public review at this Indian Affairs address during business hours. Before including your address, phone number, e-mail address, or other personal identifying information in your comment, you should be aware that your entire comment—including your personal identifying information—may be made publicly available at any time. 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.