BIA-4432 Form – Fill Out and Use This PDF

FORM BIA – 4432	OMB Control # 1076-0160
	Expiration Date: 11/30/2014

VERIFICATION OF INDIAN PREFERENCE FOR EMPLOYMENT

IN THE BUREAU OF INDIAN AFFAIRS AND THE INDIAN HEALTH SERVICE

Complete one of the categories as stated in the Instructions and submit this form with your application for Federal employment.

CATEGORY A - MEMBERS OF FEDERALLY-RECOGNIZED INDIAN TRIBES, BANDS OR COMMUNITIES

This is to certify that the person named below is a member of the tribe shown:

______________________________________________		_____________	_____________________
Full Name	Enrollment No.	Date of Birth	Tribal Affiliation

I certify that the above information was taken from the official membership records of the ________________ Tribe (or records

maintained for the Tribe by the BIA) and acknowledge that falsification and misrepresentation of this information is punishable under Federal Law, 18 U.S.C. 1001.

		And if required, verification by the BIA Official maintaining the
Certification by Tribal Official:		official tribal rolls that the individual is listed on enrollment
		list maintained by the BIA at the request of	the tribe.
____________________________	________	_______________________________________ ________
Signature	Date	Signature of BIA Official	Date
______________________________________		__________________________________	_____ ________
Print Name & Title of Tribal Official		Name/Title	Agency

CATEGORY B - DESCENDANTS OF MEMBERS OF FEDERALLY-RECOGNIZED INDIAN TRIBES, BANDS OR COMMUNITIES WHO WERE RESIDING ON ANY INDIAN RESERVATION ON JUNE 1, 1934

I certify that the person named below has established to my satisfaction that he/she is a descendant of an enrolled member of the tribe named below and that he/she was living on an Indian reservation on June 1, 1934. The applicant’s family history is outlined on

the attached family history chart.

_________________________________________________________________________________		_______________
Full Name		Date of Birth
____________________________________________________	__________________________________________
Reservation of Residence on June 1, 1934	Full Name of Ancestor & Tribal Affiliation
Title and source of records upon which this is based:	________________________________ ________
	BIA Official	Date
___________________________________________
	__________________________	________________
	Title	Agency

CATEGORY C - PERSONS WHO POSSESS AT LEAST ONE-HALF DEGREE INDIAN BLOOD DERIVED FROM TRIBES INDIGENOUS TO THE UNITED STATES.

I certify that I have reviewed the documentation to support the below listed individual’s claim to possess at least one-half degree Indian blood. The applicant’s family history is outlined on the attached family history chart and official records.

__________________________________________________	______________ ___________________________________
Full Name	Date of Birth	Degree of Blood and Tribal Derivation
Title & Source of Records upon which this is based:	____________________________________		________
		BIA Official	Date
___________________________________________
 Official Records of Tribal Affiliation & Blood Degree	_______________________________ ________________
 State or Academic Recognition of Indigenous Status		Title	Agency

FORM BIA – 4432	OMB Control # 1076-0160
	Expiration Date: 11/30/2014

CATEGORY D - ALASKA NATIVE

I certify that the person named below is a member of an Alaska Native Tribe; or, an individual whose name appears on the roll of Alaska Natives prior to July 31, 1981, and not subsequently disenrolled; or, an individual who was issued stock in a Native corporation pursuant to 43 U.S.C. 1606(g)(1)(B)(i).

_____________________________________________	_____________	_______________________________________
Name	Date of Birth	Alaska Native Village/Corporation/Roll
Title and source of records upon which this is based:
_____________________________________________________		____________________________	________
		BIA Official	Date
		____________________________	___ _____
		Title	Agency

INSTRUCTIONS FOR COMPLETING FORM BIA-4432

1.It is the responsibility of the individual to establish evidence of entitlement to Indian preference. Applicants must submit as much background information as possible to verify eligibility for Indian preference. Falsification or misrepresentation of information is punishable under Federal Law, 18 U.S.C. 1001.

CATEGORY A

MEMBERS OF FEDERALLY-RECOGNIZED INDIAN TRIBES, BANDS OR COMMUNITIES. If you are a member of a Federally-recognized tribe, you must request that your tribe complete this category. One of the following procedures will apply and you will be advised by your tribe:

If your tribe has contracted or compacted the maintenance of tribal enrollment records under the Indian Self-Determination and Education Assistance Act, Pub. L. 93-638, as amended, 25 U.S.C. 450, a verification signed by an authorized Tribal Representative(s) is sufficient.

If your tribe does not maintain tribal enrollment records, the tribe must certify that you are a member and you must submit the form to the BIA official who maintains the official roll for the tribe.

CATEGORY B AND C

·DESCENDANTS OF MEMBERS OF FEDERALLY RECOGNIZED INDIAN TRIBES, BANDS OR COMMUNITIES WHO WERE RESIDING ON ANY INDIAN RESERVATION ON JUNE 1, 1934

·PERSONS WHO POSSESS AT LEAST ONE-HALF DEGREE INDIAN BLOOD DERIVED FROM TRIBES INDIGENOUS TO THE UNITED STATES

If you are claiming preference based on any of these categories, you should provide as much information as possible regarding your family history. This will be the only information which the BIA will have to certify your lineal descent.

If you are claiming preference based upon lineal descent from a member of a federally recognized tribe, band or community, you must also document that you were residing within the present boundaries of the reservation on June 1, 1934.

If you possess one-half degree Indian blood from a tribe indigenous to the United States, you must submit state or academic records that document this status, as well as official records that establish your degree of Indian blood, such as census records. You must also complete the attached FAMILY HISTORY.

FORM BIA – 4432	OMB Control # 1076-0160
	Expiration Date: 11/30/2014

Category D

ALASKA NATIVE OR DESCENDANT OF AN ALASKA NATIVE. You may contact the Bureau of Indian Affairs office servicing your village or corporation for completion of this category.

2.INSTRUCTIONS TO BIA OFFICIALS:

This form has been designed for the verification that an applicant is entitled to Indian preference in employment. If category A membership is verified through records maintained for the Tribe by the BIA, a tribal representative must also sign the verification. If the applicant does not meet the tribal enrollment criteria, the form should not be completed. If the applicant cannot document at least one-half degree Indian blood derived from tribes indigenous to the United States, the form should not be completed. Upon verification by a BIA Regional Director, Superintendent or other designed responsible BIA official, the applicant will be entitled to preference in employment.

3.INSTRUCTIONS TO PERSONNEL OFFICERS:

Receipt of a properly verified FORM BIA 4432, together with an acceptable application, “Personal Qualifications Statement”, entitles an applicant to preference in employment.

4.PAPERWORK REDUCTION ACT NOTICE:

The information collection is 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 1076-0160. This information is collected to verify that individuals are eligible for preference when appointments are made to vacancies in positions in the Bureau of Indian Affairs. It is estimated that it takes the applicant about 30 minutes to complete this form. A Federal 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. If you have any questions regarding the burden estimation, please contact: Information Collection Clearance Officer – Indian Affairs, 1849 C Street, NW, MS-4141, Washington, DC 20240.

5.PRIVACY ACT STATEMENT:

This information is collected as provided pursuant to the Privacy Act, 5 U.S.C. 552a, for individuals completing application forms for Federal employment with the Bureau of Indian Affairs (DOI) or the Indian Health Service (DHHS). We are authorized to collect information to verify Indian ancestry or Indian tribal membership by 25 U.S.C. 2, 4 Stat. 564 and 15 Stat. 228; 25 U.S.C. 9, 4 Stat. 738; 25 U.S.C. 43; 36 Stat. 272; 25 U.S.C. 44, 28 Stat. 313; 25 U.S.C. 46, 22 Stat. 88 and 23 Stat. 697; 25 U.S.C. § 348, 24 Stat. 398 and 31 Stat. 1085; 25 U.S.C. 472, 48 Stat. 986; 25 U.S.C. § 472a, 93 Stat. 1057 and 94 Stat. 695; 25 U.S.C. 479, 48 Stat. 988; and 5 U.S.C. 8336. The information collected will be used to determine eligibility for Indian preference and may be disclosed to the Department of the Interior Office of Personnel, the United States Office of Personnel Management, and the Indian Health Services Office of Personnel. The system of records notice is OS-79, General personnel Records, 64 FR 20010 (April 23, 1999).

6.EFFECTS OF NON-DISCLOSURE:

Disclosure of the information requested on this form (Form BIA 4432) is voluntary. However, consideration for Indian preference in employment under 25 CFR Part 5 requires proof that (a) you are a member of any recognized Indian tribe currently under Federal jurisdiction; (b) you are a descendant of a member residing within the present boundaries of any Indian reservation on June 1, 1934; (c) you are an Eskimo or another aboriginal person of Alaska as defined by the Alaska Native Claims Settlement Act (43 U.S.C. 1601 et seq.); or (d) you possess one- half or more Indian blood of tribes that are indigenous to the United States. Indian Reorganization Act of June 18, 1934, 25 U.S.C. 472.