5-5524 Application for Allocation of Grazing Privileges

Form 5-5524 OMB No. 1076-0157

Expires 02/28/2007

UNITED STATES

DEPARTMENT OF THE INTERIOR

BUREAU OF INDIAN AFFAIRS

APPLICATION FOR ALLOCATION OF GRAZING PRIVILEGES

________________________________ RESERVATION _____________________________AGENCY

I (We) the undersigned enrolled member(s) of the _______________ Indian Tribe hereby apply for an allocation of grazing privileges without competitive bidding as authorized by 25 CFR 166.205. Allocated grazing privileges are requested on the following lands:

Range Unit (s) or Areas Desired: Proposed Grazing Season:

(If year‑long, insert the word year‑long instead of dates.)

__________________________________________________________ From __________________ To ___________________

__________________________________________________________ From __________________ To ___________________

__________________________________________________________ From __________________ To ___________________

I (We) certify that the number of livestock over 6 months of age owned by me (us) and to be grazed under my (our) exclusive control and supervision are as follows:

Number of Kind of Brand and Recorded Owner If Mortgaged, Name of

Livestock Livestock Location of Brand Holder of Mortgage

__________ __________ _____________ ___________________________ _____________________________________

__________ __________ _____________ ___________________________ _____________________________________

__________ __________ _____________ ___________________________ _____________________________________

__________ __________ _____________ ___________________________ _____________________________________

I (We) apply for total allocated privileges for the following Number of Kind of

number and kind of livestock: Livestock Livestock

1. Owned and listed above _____________ ______________

2. In addition to those listed above _____________ ______________

Total applied for _______________ X X X X X

If this application requests allocated grazing privileges for more livestock than the applicant owns, state briefly the plans made to acquire the additional livestock, including financial arrangements for purchase.

Paperwork Reduction Act: This information is collected to manage agriculture and grazing leases. The information is supplied by a respondent to obtain or retain a benefit, that is, a lease. It is estimated that responding to the request will take an average of 20 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 Clearance Officer, Bureau of Indian Affairs, 625 Herndon Parkway, Herndon, VA 20170. Note: comments, names and addresses of commentors 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.

(Complete the reverse side)

Page 2 of Application for Allocation of Grazing Privileges

If the applicant intends to graze any livestock owned by another person, list the number, kind, and ownership of such livestock:

Number of Kind of Brand and Tribal

Livestock Livestock Location Name and Address of Owner Member?

______________ ________________ __________ ____________________________________ Yes ____ No ____

______________ ________________ __________ ____________________________________ Yes ____ No ____

______________ ________________ __________ ____________________________________ Yes ____ No ____

______________ ________________ __________ ____________________________________ Yes ____ No ____

Total X X X X X X X X X X X X X X X X X X X X X X X X

List here the description and acreage of any land owned or controlled by you that is available for the grazing or pasturing of your livestock. State how many livestock the land will support and for .how long. (Attach additional sheet if needed.)

Do you now allow or intend to allow anyone else to graze or pasture their livestock on any of the land you exclusively own or control (not shared with others) rather than graze your own livestock on it?

Yes _____ No _____ If yes, state how many livestock: ________________________

I (We) agree to abide by Title 25, Code of Federal Regulations, Part 166, and all Tribal grazing regulations and, if a grazing permit is issued, to comply fully with its terms.

WITNESS: Date:________________________________

______________________________________________ __________________________________________________________

Applicant

______________________________________________ ____________________________________________________________

Applicant