Application for Consolidation by Sale

Form X-XXXX DRAFT OMB No. 1076-0xxx

Expires: mm/dd/yyyy

UNITED STATES

DEPARTMENT OF THE INTERIOR

BUREAU OF INDIAN AFFAIRS

APPLICATION FOR CONSOLIDATION BY SALE

(WRITE ALL NAMES IN FULL)

1. Applicant Name:______________________________________________________________________________________

2. Applicant Social Security Number or Tribal Identification Number __________________________________________

3. Applicant Address:____________________________________________________________________________________

________________________________________________________________________________________________________

4. Applicant Mailing Address, if different from above________________________________________________________

________________________________________________________________________________________________________

5. I (we) request that a consolidation by sale be conducted for the following highly fractionated parcel

(provide or attach a legal description of the parcel):

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

________________________________________________________________________________________________________­­_.

6. I (we) own the following specific ownership interest(s) in the highly fractionated parcel described in Number 5 (provide or attach a legal description of the interest):

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

________________________________________________________________________________________________________­­_.

**Please be aware that the one-time cost of mailing notices of the consolidation-by-sale proceeding to the other interest owners in the parcel (or a bond to cover the cost) may be required the Applicant.**

FORM CONTINUED ON THE FOLLOWING PAGE.

7. I (we) hereby certify that I am (we are) one of more of the following:

(Check all that apply)

T he Indian tribe with jurisdiction over the trust or restricted interests in the parcel

A member, or person eligible to be a member, of the Indian tribe with jurisdiction over the parcel

A member, or person eligible to be a member, of an Indian tribe without jurisdiction over the parcel AND the owner of an undivided interest in the parcel (at the time of sale)

A lineal descendant of the original allottee of the parcel who is a member, or eligible to be a member, of an Indian tribe

A lineal descendant of the original allottee of a parcel located in California that is not within an Indian tribe’s reservation or not otherwise subject to an Indian tribe’s jurisdiction, who is a member, or eligible to be a member of an Indian tribe or owns a trust or restricted interest in a parcel.

8. I (we) will notify the BIA immediately if my (our) status under the listed categories changes as the consolidation-by-sale proceeding advances (for example, because you have sold your interest or inherited an additional interest).

____________

(Initial)

9. I hereby acknowledge that I will be responsible for paying the costs or posting bond for the costs of mailing and publishing notice of this application, unless waived by the Secretary.

____________

(Initial)

Submitted by: _____________________________

(Applicant Signature)

Paperwork Reduction Act: This information is collected to record a request for consolidation by sale in accordance with BIA regulations at 25 U.S.C.465 AND 25 U.S.C. 2202. The information is supplied by a respondent to obtain a benefit, that is, the opportunity to subject a parcel to sale, and to bid on that parcel. It is estimated that responding to the request will take an average of 30 minutes to complete. This includes the amount of time it takes to understand directions, gather the information and fill out the form. If you wish to make comments on the form, please send them to the Information Collection Control Officer, Bureau of Indian Affairs, 625 Herndon Parkway, Herndon, VA 20170. Note: comments, names and addresses of commentators are available for public review during regular business hours. If you wish us to withhold this information, you must state this prominently at the beginning of your comment. We will honor your request to the extent allowable by law. In compliance with the Paperwork Reduction Act of 1995, as amended, the collection has been reviewed by the Office of Management and Budget and assigned a number and expiration date. The number and expiration date are at the top right corner of the form. Please note that an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless there is a valid OMB clearance number.

Privacy Act Statement: This information collection request requires personal information protected by the Privacy Act. The information is used to ensure that you are eligible for a consolidation by sale of lands. . It will not be released to anyone without your permission except if the information is used as part of assigned duties. This may include the Department of Justice, members of Congress, Interior employees, and interested parties.