BASSC-1 BASSC-1: State Certifying Official (SOC) Apointment Form

OMB Control No.: 0607-0151
Expiration Date: 11-30-2024

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:

FORM

BASSC-1

ST_ABBR

Name:

Job Title:
Department:
Address:
City:

State:

Telephone:

Email:

ZIP Code:

State Certification materials will be emailed to the individual you appoint as the SCO. You may either confirm the
current SCO above or appoint another individual to this position. Complete the section below if the contact
information for the appointed SCO if different from above.

I confirm the contact person listed
above as the SCO.

I appoint the following individual as
the new SCO:

OR

Name:
Job 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:

Date:

Email this completed form to .

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 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.

(07-2024)