(Attachment to Family History Chart

OMB Control # 1076-0160

Expiration Date:XX/XX/XXXX

Family History Chart

For Categories B, C & D

			(IV) Great-grandfather BD:_____________ Tribe:
		(III) Grandfather BD:_____________ Tribe:
			(IV) Great-grandmother BD:_____________ Tribe:
	(II) Father BD:_____________ Tribe:
			(IV) Great-grandfather BD:_____________ Tribe:
		(III) Grandmother BD:_____________ Tribe:
			(IV) Great-grandmother BD:_____________ Tribe:
(I) Applicant BD:_____________ DOB:_____________ Tribe:
			(IV) Great-grandfather BD:_____________ Tribe:
		(III) Grandfather BD:_____________ Tribe:
			(IV) Great-grandmother BD:_____________ Tribe:
	(II) Mother BD:_____________ Tribe:
			(IV) Great-grandfather BD:_____________ Tribe:
		(III) Grandmother BD:_____________ Tribe:
			(IV) Great-grandmother BD:_____________ Tribe: