BASSC 1L State Certification Program

FORM

BASSC-1L (06-2021)

OMB Control No.: 0607-0151 Expiration Date: 11/30/2023

Boundary and Annexation Survey (BAS) State Certification
State Certifying Official (SCO) Appointment Form
The contact information for the individual currently responding to the BAS State Certification program
in your state is provided in the space below:
Name:

ST_ABBR

Title:
Department:
Address:
City:

State:

Telephone:

Email:

Zip Code:

State Certification materials will be emailed to the individual you appoint as the State Certifying Official (SCO). You
may either confirm the current SCO above or appoint another individual to this position. Please provide the contact
information for the appointed SCO if different from above:
I confirm the contact person listed
above as the SCO.

OR

I appoint the following individual as
the new SCO:

Name:
Title:
Department:
Address:
City:

State:

Telephone:

Fax:

Zip Code:

Email:
Please sign below to indicate that you approve the information provided on this form.
Governor’s Signature: __________________________________________________
Please email or mail this
completed form to the U.S.
Census Bureau:

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

Date:

__________________

Email Address: geo.bas@census.gov

A list of annexations received through the BAS program from 2000- is available online at:
.
We estimate that participating in the Boundary and Annexation Survey State Certification Program 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 program under the legal authority of the Title 13 United States Code, Section 6.