BAS-3 BAS 3 - MCD Form

FORM

BAS-3 (05-2021)

OMB Control No.: 0607-0151 Expiration Date: xx-xx-2024

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU

BOUNDARY AND ANNEXATION SURVEY (BAS)
MINOR CIVIL DIVISIONS (MCD)
Boundaries as of —
To report changes to your government, please complete this form.

● Answer all questions on the form completely.
● If there are no boundary changes to report, please email , call 1–800–972–5651, or
respond electronically at .
● Please do not return all of the maps. Return only the maps with changes.
● Return the completed form(s) and updated map(s) using the provided envelope and return label.

GENERAL
INSTRUCTIONS

Type

A. Minor civil division
STATE
CODE

BAS ID

County
MCD
CODES

COUNTY
CODE

State

ANSI

FIPS

IMPORTANT – ANNOTATE EACH CHANGE ON THE MAP(S) WITH THE APPROPRIATE DOCUMENTATION ACCORDING TO THE
INSTRUCTIONS PROVIDED IN THE BAS RESPONDENT GUIDE. Please update the map(s) USING THE APPROPRIATE COLORED PENCILS.
Question 1

NAME OR TYPE CHANGE – Please mark (X) the applicable boxes.

1a. Are the name and type (i.e. town, township, plantation, location, Reservation) correct as shown in Box A at the top of the page?
Yes – Continue with question 2.

Effective date of change
Date (Month/Day/Year)

Type

Name

No – Enter correction here.
Question 2

LEGAL BOUNDARY CHANGES – Please mark (X) the applicable boxes.
Time period:

2a. Have there been any legal boundary changes to this minor civil division during the time period shown above?
Yes – Please record all legal change actions (annexations, deannexations and other actions) in the Documentation of Changes section
of the form and update the map(s) USING THE ENCLOSED RED PENCIL. Continue with question 2b.
No – Continue with question 2b.
2b. Has your minor civil division had any other types of changes (i.e. consolidations/mergers, been annexed, been dissolved/disincorporated, etc.)
that have affected its boundaries or governmental status during the time period shown above?
Yes – Complete question 2c.

No – SKIP to question 2d.

2c. This MCD has: Mark (X) one of the
following
(1)

(2)

(3)

consolidated/merged with
been annexed by

Government:

Enter the effective date of change and
the Ordinance or Resolution Number:

(Month/Day/Year)
Ordinance/Resolution No.

Name of government with which minor civil division consolidated/merged

Date/Number

Name of government annexing this minor civil division

Date/Number

Name of government being dissolved/disincorporated

Date/Number

. . . . . .

. . . . . . . . . . .

dissolved/disincorporated

. . . . . .
Date/Number

(4)

Other – Provide an explanation.

2d. Are there any legal boundary changes that occurred before the period shown above that do not appear on the enclosed map(s)?
Yes – Please make the necessary updates to the map(s). Continue with question 3.
Question 3

No – Continue with question 3.

OTHER CHANGES – Please mark (X) the applicable boxes.

3a. Besides legal changes, are there any boundary corrections that need to be made to your boundary on the map(s)?
Yes – Please correct the map(s) USING THE ENCLOSED RED PENCIL and the initials BC to indicate a boundary correction.
Enter the total number of boundary corrections that you made to the maps.

Continue with question 4.

No – Continue with question 4.
We estimate that participating in the Boundary and Annexation Survey will take 7.5 hours on average. Send comments regarding this burden estimate or any
other aspect of this collection of information, including suggestions for reducing this burden, using Paperwork Reduction Project 0607-0151 as the subject, to
. This collection has been approved by the Office of Management and Budget (OMB). The eight-digit OMB approval number that
appears at the upper right of the form confirms this approval. If this number were not displayed, we could not conduct this survey. The Census Bureau conducts
this survey under the legal authority of the Title 13 United States Code, Section 6.

Question 4

CONTACT INFORMATION – Please fill in your contact information in the space provided below.
BAS Respondent

Mailing
Address

Mark (X) one government type for the BAS Respondent.

(The BAS Respondent is the person filling out this form.)

Local

County

Regional

Name
Address
Position
Department

City

Telephone

(

)

Fax

(

)

Ext.

State
E-mail

Mark (X) this box if the BAS Respondent
is the same as the BAS Mailing Contact.

Question 5

Mark (X) this box if the BAS Respondent is the
same as the Highest Elected Official.

CONTACT INFORMATION – Please fill in or correct the content information below.
Mark (X) one government type for the BAS mailing contact.

BAS Mailing Contact

Mailing
Address

ZIP code

(Provide address where BAS materials should be sent.)

Local

County

Regional

Name
Address
Position
Department

City

Telephone

(

)

Fax

(

)

Ext.

State

ZIP code

E-mail

Highest Elected Official

Mailing
Address

(for MCD only)

Name
Address
Position
Department

City

Telephone

(

)

Fax

(

)

RETURN FORMS TO:

U.S. Census Bureau
National Processing Center
ATTN: BAS RETURNS, BLDG 63E
1201 East 10th Street
Jeffersonville, IN 47132

Ext.

State

ZIP code

E-mail

Thank you for your participation and timely response.
Questions?

Telephone: 1-800-972-5651
Email:
Website:

CENSUS USE ONLY

SPECIAL INSTRUCTIONS (If any)

FORM BAS-3 (05-2021)

Date
processed

Clerk ID
processed

Date
verified

Clerk ID
verified

Date form
keyed

Date GPP
updated

S/S change

Map received

Map
change

S/S no
change

Other map

Map no
change

PLAT/
Description

Map
signed

Letter

Documentation of Changes
MINOR CIVIL DIVISIONS
Minor civil division

Type
STATE
CODE

BAS ID

County
COUNTY
CODE

MCD
CODES

State

ANSI

FIPS

SPECIAL INSTRUCTIONS (If any)

Please follow the instructions below to review the preprinted entries for correctness and completeness and make changes as necessary. For
new legal changes, use the provided spaces to print the requested information for all annexations, deannexations, and other changes that
have occurred during the previous year(s).
Instructions for Entering Data in Columns
(1) Change – Enter A for annexations, D for deannexations, B for boundary corrections, or O for other changes.
(2) Authorization – Enter the authorization type. (O = Ordinance, R = Resolution, L = Local Law, S = State-level action, and X = Other)
(3) Authorization – Enter the authorization number for the change you are reporting.
(4) Date – Enter the effective date of the change. (Month, day, year)
(5) Minor Civil Division (MCD) – Enter the name of the minor civil division in which the change occurred.
(6) Area – Enter the estimated size (in tenths of acres) of the annexation, deannexation or other change.
Change
Type
A/D/O
(1)

FORM BAS-3 (05-2021)

Authorization
Type
O/R/L/S/X
(2)

Authorization Number
(3)

Date
Month/Day,
Year

Minor Civil Division
Name

Area
Acres
(tenths)

(4)

(5)

(6)

Documentation of Changes – Continued
MINOR CIVIL DIVISIONS
Minor civil division

Type
STATE
CODE

BAS ID

County
COUNTY
CODE

MCD
CODES

State

ANSI

FIPS

SPECIAL INSTRUCTIONS (If any)

Change
Type
A/D/O
(1)

FORM BAS-3 (05-2021)

Authorization
Type
O/R/L/S/X
(2)

Authorization Number

Date
Month/Day,
Year

Minor Civil Division
Name

Area
Acres
(tenths)

(3)

(4)

(5)

(6)