This certifies that the number of Indian children under age 13 (as defined in the CCDF section of the 102-477 plan) who reside on or near the reservation or service area (as defined in the CCDF section of the
102-477 plan) is: ____________ (number)

This count shows the number of Indian children under age 13 as of ____________ (date)

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Signature of Individual Authorized to Act for the Tribe