Certificate Blood Form PDF Details

A blood form is a document that lists the blood type of an individual. It is used to help healthcare professionals identify the correct blood type for transfusions and other medical treatments. The most common type of blood form is the ABO form, which lists the blood types A, B, AB, and O. There are also other forms that list additional blood types. Certificate blood forms are usually used to document the blood type of a donor or recipient. They can be used to prove that a particular person's blood matches the specific requirements for a particular medical treatment.

QuestionAnswer
Form NameCertificate Blood Form
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namescdib, certificate degree indian blood form, certificate of indian blood, certificate of indian blood application navajo

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OMB Control #1076-0153

Expiration Date: 03-31-2021

BUREAU OF INDIAN AFFAIRS

CERTIFICATE OF DEGREE OF INDIAN OR ALASKA NATIVE BLOOD

INSTRUCTIONS

All portions of the Request for Certificate of Degree of Indian or Alaska Native Blood (CDIB) must be completed. You must show your relationship to an enrolled member(s) of a federally recognized Indian tribe, whether it is through your birth mother or birth father, or both. A federally recognized Indian tribe means an Indian or Alaska Native tribe, band, nation, pueblo, village, or community which appears on the list of recognized tribes published in the Federal Register by the Secretary of the Interior (25 U.S.C. 5131).

Your degree of Indian blood is computed from lineal ancestors of Indian blood who were enrolled with a federally recognized Indian tribe or whose names appear on the designated base rolls of a federally recognized Indian tribe.

You must give the maiden names of all women listed on the Request for CDIB, unless they were enrolled by their married names.

A Certified Copy of a Birth Certificate is required to establish your relationship to a parent(s) enrolled with a federally recognized Indian tribe(s).

If your parent is not enrolled with a federally recognized Indian tribe, a Certified Copy of your parent’s Birth or Death Certificate is required to establish your parent’s relationship to an enrolled member of a federally recognized Indian tribe(s). If your grandparent(s) were not enrolled members of a federally recognized Indian tribe(s), a Certified Copy of the Birth or Death Certificate for each grandparent who was the child of an enrolled member of a federally recognized Indian tribe is required.

Certified copies of Birth Certificates, Delayed Birth Certificates, and Death Certificates may be obtained from the State Department of Health or Bureau of Vital Statistics in the State where the person was born or died.

In cases of adoption, the degree of Indian blood of the natural (birth) parent must be proven.

Please return your request and supporting documents to the Agency from whom you receive services. Incomplete requests will be returned with a request for further information. No action will be taken until the request is complete.

 

 

 

 

 

 

 

 

 

 

OMB Control #1076-0153

 

 

 

 

 

 

 

 

 

 

Expiration Date: 03-31-2021

 

 

 

 

 

 

 

 

 

 

Page: 1

 

 

 

 

 

 

BUREAU OF INDIAN AFFAIRS

 

 

 

 

 

REQUEST FOR CERTIFICATE OF DEGREE OF INDIAN OR ALASKA NATIVE BLOOD

Requester’s Name (list all names by which Requester

Requester’s Address (including zip code):

 

 

Date Received by

is or has been known):

 

 

 

 

 

 

 

 

Bureau of Indian

 

 

 

 

 

 

 

 

 

 

Affairs:

 

 

 

 

 

 

 

 

Paternal Great

Grandfather’s

Name:

Requester’s Date of Birth:

 

 

 

 

Paternal Grandfather’s Name:

Tribe:

 

 

 

 

 

Father’s name:

 

Roll No:

 

 

 

 

 

 

 

 

DOB:

Deceased/Year____

 

 

 

 

 

 

Tribe:

 

Paternal Great Grandmother’s Name:

Requester’s Place of Birth:

 

 

 

 

 

Tribe:

 

 

 

 

 

 

Roll No:

 

Roll No:

 

 

 

 

 

Tribe:

 

 

DOB:

Deceased/Year____

DOB:

Deceased/Year____

 

 

 

 

 

 

 

Paternal Great

Grandfather’s Name:

 

 

 

Roll No.:

 

 

 

 

 

 

 

 

 

Paternal Grandmother’s Name:

Tribe:

 

 

Is Requester Adopted?

 

DOB:

 

 

Roll No:

 

 

 

 

 

 

 

DOB:

Deceased/Year____

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Deceased

Yes

No

Tribe:

 

Paternal Great Grandmother’s Name:

 

 

 

Year____

 

 

Roll No:

Deceased/Year____

Tribe:

 

 

 

 

 

 

 

 

DOB:

Roll No:

 

 

Are Requester’s Parents Adopted?

 

 

 

 

DOB:

Deceased/Year____

Yes

No

 

 

 

 

 

 

Maternal Great Grandfather’s Name:

 

 

 

 

 

 

Maternal Grandfather’s Name:

Tribe:

 

 

 

 

 

 

 

 

Roll No:

 

 

If Yes, list natural (birth)

 

Mother’s Name:

 

 

 

DOB:

Deceased/Year____

parents: (If known)

 

 

Tribe:

 

Maternal Great

Grandmother’s Name:

 

 

 

 

 

 

 

Tribe(s) with which Requester

 

 

 

 

Roll No:

 

Tribe:

 

 

 

 

 

 

DOB:

Deceased/Year____

Roll No:

 

 

is enrolled:

 

 

Tribe:

 

 

 

 

DOB:

Deceased/Year____

Roll Nos:

 

 

 

 

 

 

Maternal Great Grandfather’s Name:

 

 

 

 

 

 

 

 

 

 

Roll No.:

 

 

 

 

Tribe:

 

 

 

 

 

 

 

 

Maternal Grandmother’s Name:

Roll No:

 

 

 

 

 

DOB:

 

 

DOB:

Deceased/Year____

 

 

 

 

 

 

Tribe:

 

Maternal Great Grandmother’s Name:

 

 

 

Deceased

Yes

No

 

Tribe:

 

 

 

 

 

Year____

 

 

Roll No:

 

Roll No:

 

 

 

 

 

 

 

DOB:

Deceased/Year____

DOB:

Deceased/Year____

 

 

 

 

 

 

SUBMIT TO: BIA AGENCY FROM WHOM YOU RECEIVE SERVICES

All BIA Agency Offices are listed in the Tribal Leaders Directory.

If you need help with locating the BIA AGENCY FROM WHOM YOU RECEIVE SERVICES,

please contact the Office of Indian Services at 202-513-7640.

OMB Control #1076-0153

Expiration Date: 03-31-2021

Page: 2

NOTICES AND CERTIFICATION

NOTICE OF APPEAL RIGHTS.

When you receive your CDIB, you must review it for the correct name spelling, birth dates, and blood degrees. If you believe that there are any mistakes on the CDIB, you must give a written request for corrections and provide supporting documentation to the issuing officer within 45 days (60 for Alaska tribes) of the date on the letter. If you fail to meet this deadline, appeal rights will be lost. If the issuing officer decides that corrections are not needed, he or she will send a written determination with an explanation through certified mail to you and provide you with a copy of the appeals procedures.

If you are denied a CDIB, you will be given a written determination with an explanation for the denial and a copy of the appeal procedures.

PAPERWORK REDUCTION ACT STATEMENT

The information collection requirement has been approved by the Office of Management and Budget under the Paperwork Reduction Act of 1995, 44 U.S.C. 3507(d), and assigned clearance number 1076-0153. The agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Information is collected when individuals seek certification that they possess sufficient Indian blood to receive Federal program services based upon their status as American Indians or Alaska Natives. The information collected will be used to assist in determining eligibility of the individual to receive Federal program services. The information is supplied by a respondent to obtain a Certificate of Degree of Indian or Alaska Native Blood. It is estimated that responding to the request will take an average of 1.5 hours to complete. This includes the amount of time it takes to gather the information and fill out the form. If you wish to make comments on the burden imposed by the form, please send them to the Information Collection Clearance Officer, Office of the Assistant Secretary - Indian Affairs, 1849 C Street, NW, Washington, DC 20240. DO NOT SUBMIT YOUR CDIB REQUEST TO THIS ADDRESS; you should instead submit your CDIB request to the BIA Agency from whom you receive services. Note: comments, names and addresses of commentators are available for public review during regular business hours. If you wish us to withhold this information, you must state this prominently at the beginning of your comment. We will honor your request to the extent allowable by law. In compliance with the Paperwork Reduction Act of 1995, as amended, the collection has been reviewed by the Office of Management and Budget, and assigned a number and expiration date. The number and expiration date are at the top right corner of the form.

PRIVACY ACT STATEMENT.

This information is collected pursuant to the Privacy Act, 5 U.S.C. 552a. Pursuant to system of record notice, Tribal Enrollment Reporting and Payment System, Interior/BIA-7, the Bureau of Indian Affairs will not disclose any record containing such information without the written consent of the respondent unless the requestor uses the information to perform assigned duties. The primary use of this information is to certify that an individual possesses Indian blood to receive Federal program services. Examples of others who may request the information are U.S. Department of Justice or in a proceeding before a court or adjudicative body; Federal, state, local, or foreign law enforcement agency; Members of Congress; Department of Treasury to effect payment; a Federal agency for collecting a debt; and other Federal agencies to detect and eliminate fraud.

NOTICE OF EFFECTS OF NON-DISCLOSURE.

Disclosure of the information on this CDIB request is voluntary. However, proof of Indian blood is required to receive Federal program services.

NOTICE OF STATEMENTS AND SUBMISSIONS.

Falsification or misrepresentation of information provided on this request is punishable under Federal Law, 18 U.S.C. 1001. Conviction may result in a fine and/or imprisonment of not more than 5 years.

I request a CDIB, and certify that I have read the instructions, and above notices about my request for a CDIB. I further certify that the information which I have provided with this request to the Bureau of Indian Affairs is true and correct.

________________________________________________________

___________________________

(Requester’s signature)

(date)

 

 

SUBMIT TO: BIA AGENCY FROM WHOM YOU RECEIVE SERVICES

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If you want to fill out this form, be certain to provide the required details in every blank:

1. The certificate of indian blood application necessitates certain information to be typed in. Be sure the subsequent blanks are filled out:

Step number 1 in submitting cdib

2. After this segment is finished, you should add the needed particulars in Roll Nos, Tribe, Roll No, DOB, Maternal Grandmothers Name, Deceased Yes No Year, Tribe Roll No DOB, DeceasedYear, Maternal Great Grandfathers Name, DeceasedYear, DeceasedYear, SUBMIT TO BIA AGENCY FROM WHOM YOU, All BIA Agency Offices are listed, If you need help with locating the, and please contact the Office of so that you can go to the next step.

Part no. 2 of completing cdib

3. Completing I request a CDIB and certify that, Requesters signature, date, and SUBMIT TO BIA AGENCY FROM WHOM YOU is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

Step no. 3 in filling in cdib

Be very careful when filling out date and Requesters signature, since this is where many people make some mistakes.

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