Name of Tribal Lead Agency:________________________________________________
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)
__________________________________
Signature of Individual Authorized to Act for the Tribe
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