1 - OSBP
|1. |Name of Firm: | |
|2. |Address of Firm: | |
|3. |Firm POC: | |
|4. |Telephone Number: | |
|5. |Email: | |
|6. |a. Firm is owned and controlled by: |
| |a. Individual. Owner’s Name and title: |
| | |
| |b. Tribe Owned. Tribe’s Name: |
| | |
| |c. Alaska Native Corporation. ANC name: |
| | |
| |d. Native Hawaiian Organization. NHO name: |
| |b. If owned by an individual, does the person identified in block (6a) above own 51% or more of the firm? |
| | |
| |a. Yes b. No (If “No,” each Native American owner must submit a separate Self-Certification Form that, in combination with the person identified in |
| |block 5a, results in 51% or more ownership of the firm.) |
|7. |If block (6a) is checked above, the owner is: (Check one) |
| | |
| |a. A member of a federally recognized tribe. (Federal Register: January 14, 2015 (Volume 80, # 9 Notices] [Page 1943-1948). Name of Tribe in which you |
| |are enrolled: |
| | |
| |b. A “Native” as defined by the Alaska Native Claims Settlement Act 43 USC 1602(b) [``Native'' means a citizen of the United States who is a person of |
| |one-fourth degree or more Alaska Indian (including Tsimshian Indians not enrolled in the Metlaktla Indian Community) Eskimo, or Aleut blood, or combination|
| |thereof. The term includes any Native as so defined either or both of whose adoptive parents are not Natives. It also includes, in the absence of proof of |
| |a minimum blood quantum, any citizen of the United States who is regarded as an Alaska Native by the Native village or Native group of which he claims to |
| |be a member and whose father or mother is (or, if deceased, was) regarded as Native by any village or group. Any decision of the Secretary regarding |
| |eligibility for enrollment shall be final] |
| | |
| |c. A Native Hawaiian as defined by 25USC4221, Sec 9 |
| | |
| |d. None of the above. (you are not eligible to participate in the Indian Incentive Program) |
| |I DECLARE THAT THE FOREGOING STATEMENTS ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE, INFORMATION, AND BELIEF. |
| |______________________________________________________________ __________________________ |
| |(Signature) (Date) |
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Department of Defense Indian Incentive Program
Self-Certification Form
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