Form 5-5519 Cash Penal Bond for Grazing Permit

Form 5-5519 UNITED STATES OMB. No. 1076-0157

DEPARTMENT OF THE INTERIOR Expires: 02/28/2010

BUREAU OF INDIAN AFFAIRS

CASH PENAL BOND FOR GRAZING PERMITS

KNOW ALL MEN BY THESE PRESENTS, That I (or we), herein referred to as the permittee, herewith deposit with the

Superintendent of the ________________________ Indian Agency the sum of $ _______________ to be held as a cash penal bond to guarantee full performance of the terms of a grazing permit accepted by the permittee on Range Unit ______________of the

_________________________ Indian Reservation for a period beginning ____________________________ and terminating not

(Date)

later than __________________________________.

(Date)

It is understood that this amount will be credited on the last installment of the grazing fees due under the terms of the said permit, provided that the terms thereof have been faithfully carried out by the permittee. The permittee hereby constitutes and appoints the Superintendent and his successors in office or his agent as his (or their) attorney‑in‑fact and agrees that in case of any default in the performance of any of the conditions or stipulations of the permit, the said attorney‑in‑fact shall have full power to apply the deposit in the satisfaction of any damages, demands, or deficiency arising by reason of such default as he may deem best and the permittee hereby for himself, heirs, executors, administrators, successors, and assigns, ratify and confirm whatever said attorney‑in‑fact shall do by virtue of these presents.

IN WITNESS WHEREOF, the permittee hereunto sets his (or their) hand and seal this _____ day of ___________________

(Month / Year)

WITNESSES:

______________________________________________

______________________________________________ __________________________________________________[SEAL]

(Post-office Address) Permittee.

______________________________________________ ________________________________________________________

(Post‑office address)

______________________________________________ __________________________________________________[SEAL]

(Post-office Address) Permittee

______________________________________________ ________________________________________________________

(Post‑office address)

______________________________________________

(Post-office Address)

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 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, 1849 C Street NW, Mail Stop 4603 MIB, Washington, DC 20240. 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.