Name of Tribe/Tribal Organization __________________________________________________

Name of Tribal Lead Agency _______________________________________________________

Name of Contact _________________________________________________________________

Address _________________________________________________________________________

Telephone Number _______________________________________________________________

FAX Number _____________________________________________________________________

Estimated Amount of FY 1997 Tribal Mandatory Funds to be Used for Construction or Major Renovation $_______________________________________________

On the line above, provide a dollar estimate. The estimate must be specific; do not provide a range. The estimate should be for FY 1997 Tribal Mandatory Funds only; do not include Tribal Mandatory Funds expected to be awarded in other fiscal years or any other funding sources regardless of fiscal year.

______________________________________________________________________________

Complete and return this form so that ACF receives it no later than September 15, 1997.

Return it to the following address:

Joe Lonergan, Director
Division of Formula, Entitlement, and Block Grants
Office of Program Support
Administration for Children and Families
Room 702
370 L'Enfant Promenade, S.W.
Washington, D.C. 20447

In addition, send a copy to:

ACF Regional Administrator, DHHS/ACF

______________________________________________________________________________

PAPERWORK REDUCTION ACT. Public reporting burden for this collection of information is estimated to average 3 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. An 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. Approved OMB Number: 0970-0160, expires June 30, 2000