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SAMPLE SURVEY
January 1, 2003
SECTION ONE
SECTION ONE -
A.spacerMunicipality Name:
FIPS Code:
Type:
State:
B. County(ies), parish(es), borough(s), or other statistically equivalent area(s) (FIPS Code):
C. Minor civil division(s) (FIPS Code):
State Code:
County Code:
Municipality Code:
SECTION 1 - PERSON COMPLETING THIS FORM
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GENERAL INSTRUCTIONS:  Please complete this form within 15 days of receiving your signature code. Please also print a copy of the completed form for your records. It is importnat that all questions are answered completely. Return completed form even if no changes occurred during the period shown. If you have questions about ths form, please visit our form help section.
QUESTION 1 Please complete the following:
Signature Code:
Last Name:
First Name:
Title:
Date:
Telephone: Ext.
Fax:
Email Address:
QUESTION 2 MAILING ADDRESS
Please type necessary corrections in the box below.
NAME/TITLE
ADDRESS 1
ADDRESS 2
CITY, STATE, ZIP
QUESTION 3


 NAME, TYPE, COUNTY, OR MINOR CIVIL DIVISION CHANGE
Please check the applicable box(es) and continue to the next question.
a. Are the name and type (i.e., city, town, village, borough) of this municipality correct as shown in box A, above?
1.Yes (If yes, SKIP to question b.)
2.No
Name:  Type:   Effective Date of Change:
b. Is the list of county(ies) or statistically equivalent area(s) and minor civil division(s) within which this municipality is located correct as shown in boxes B and C, above?
1.Yes (If yes, SKIP to question 4.)
2.No (Enter the correction in item c.)
c. Enter the correct information AND the effective date of change.
A - Add
D - Delete		 County or equivalent Minor civil division name Month Day Year
    
    
    
QUESTION 4


 LEGAL BOUNDARY CHANGES DURING THIS PERIOD
January 2, 2002 through January 1 2003
Please check the applicable box(es) and continue to the next question.
a. Have there been any legal boundary changes to this municipality during the time period shown for question 4?
1.Yes (Please record all legal change actions, i.e., annexations, detachments, and other actions.)
2.No (Continue with item b.)
Name:  Type:   Effective Date of Change:
b. Has your municipality had any other types of changes affecting its boundaries or governmental status during the time period shown for question 4?
1.Yes (Complete item c.)
2.No (SKIP to question 5)
c. This municipality has (Check one):
(1)   Name of jurisdiction with which consolidated/merged:

Effective date of change:
(2)   Name of jurisdiction annexing this municipality:


Effective date of change:
(3)   Name of jurisdiction being dissolved/disincorporated:

Effective date of change:
(4)   Other:
Special Instructions:
BUREAU USE ONLY
Date Processed:
 S map:
S/S Change:
 O map:
S/S No Change:
 Map Change:
PLAT/Description:
 Map no change:
Letter:
 Map signed:


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