5-5521 Application for On/Off Permit

Form 5-5521 UNITED STATES OMB No. 1076-0157

DEPARTMENT OF THE INTERIOR Expires: 02/28/2007

BUREAU OF INDIAN AFFAIRS

CERTIFICATE AND APPLICATION FOR ON-AND-OFF GRAZING PERMIT

I (or WE), Permittee of Range Unit No. ____________ on the _________________________ reservation for the period beginning ________________, and ending ________________ DO HEREBY CERTIFY that the

(Date) (Date)

following described lands, which are within or adjoining the range unit, are legally owned, or controlled by other legal tenure, by the undersigned and are to be grazed in conjunction with the Indian Lands covered by the Grazing Permit on the said unit. Application is hereby made for an On‑and‑Off Grazing Permit pursuant to 25 CFR 166.308.

Legal Description of Lands: (Use reverse hereof if necessary)

Non‑Indian Lands:

Federal and State Lands

Other Indian Lands

Acres:

Non‑Indian: (Total)____________ ; Owned ________; Leased __________; Lease Expires__________

Federal and State : _________________________; Lease Expires ______________________________

Other Indian:______________________________; Lease Expires _______________________________________

IT IS UNDERST00D AND AGREED that the Superintendent shall establish the maximum allowable stocking of all lands to be grazed under the on‑and‑off permit and that approval of this application is made subject to the terms and conditions of the permit and applicable regulations.

__________________________________________________ __________________________________________________

(Date) (Permittee)

APPROVED:

SUPERINTENDENT:

Paperwork Reduction Act Statement: 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.