5-5519 Cash Penal Bond for Grazing Permits

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

DEPARTMENT OF THE INTERIOR Expires: _________

BUREAU OF INDIAN AFFAIRS

CASH PENAL BOND FOR GRAZING PERMITS

I (or we), ______________________________ herein referred to as the permittee, deposit with the Superintendent of the ________________________ 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 later than __________________________.

(Date) (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 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 deficiencies arising by reason of such default as he may deem best and the permittee hereby for himself, heirs, executors, administrators, successors, and assigns, ratifies and confirms 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:

______________________________________________

______________________________________________ ________________________________________________________

(Address) Permittee.

______________________________________________ ________________________________________________________

(Address)

______________________________________________ ________________________________________________________

(Address) Permittee

______________________________________________ ________________________________________________________

(Address)

______________________________________________

(Address)

APPROVED:

_______________________________________ ______________________________________________________

Superintendent.

Paperwork Reduction Act Statement: This form is covered by the Paperwork Reduction Act.  It is used to establish the respective rights and responsibilities of the respondent and the Federal government. The information is provided by respondents to obtain or retain a benefit.  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 an expiration date.  The number and expiration date are at the top right corner of the form.  An agency may not sponsor or conduct, and a person is not required to respond to, a request for information collection unless it displays a currently valid OMB Control Number.  The public reporting burden is estimated to average 20 minutes per respondent.  This includes the time needed to understand the requirements, gather the information, complete the form, and submit it to the Department.  Comments regarding the burden or other aspects of the form may be directed to the Indian Affairs Information Collection Clearance Officer, Office of Regulatory Affairs – Indian Affairs, 1849 C Street, NW, MS-4141, Washington, DC 20240.