List of Corporate Officers Form

OMB# 1076-0180 Expires XX-XXXX

Date

Superintendent Osage Agency

P. O. Box 1539 Pawhuska, OK 74056

Dear Superintendent:

The current listing of Officers and Directors of the

(Corporation), of

, is as follows:

OFFICERS	ADDRESSES
President
Vice President
Secretary
Treasurer

DIRECTORS

ADDRESSES

Respectfully,

Paperwork Reduction Act Statement: We are collecting this information subject to the Paperwork Reduction Act (44 U.S.C. 3501) to ensure authority to enter into lease on behalf of the corporate entity and ensure existence of corporate entity. Your response is voluntary and we will not share the results publicly. We may not conduct or sponsor and you are not required to respond to a collection of information unless it displays a currently valid OMB Control Number. OMB has reviewed and approved this survey and assigned OMB Control Number 1076-0180, which expires ##/##/####.

Estimated Burden Statement: We estimate the form will take you 60 minutes to complete, including time to read instructions, gather information, and complete and submit the form. You may submit comments on any aspect of this information collection to the Information Collection Clearance Officer, Office of Regulatory Affairs & Collaborative Action—Indian Affairs (RACA), U.S. Department of the Interior, 1001 Indian School Road NW, Suite 229, Albuquerque, NM 87104.

Updated March 9, 2017