5-5524 Application for Allocation of Grazing Privileges

Form 5-5524 OMB No. 1076-0157

Expires __________

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 166.218, 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 Mortgage Holder

__________ __________ _____________ ___________________________ _____________________________________

__________ __________ _____________ ___________________________ _____________________________________

__________ __________ _____________ ___________________________ _____________________________________

__________ __________ _____________ ___________________________ _____________________________________

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.

(Complete Page 2)

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:

Kind of Number of Brand and Tribal

Livestock Livestock Location Name and Address of Owner Member?

______________ ________________ __________ ____________________________________ Yes ____ No ____

______________ ________________ __________ ____________________________________ Yes ____ No ____

______________ ________________ __________ ____________________________________ Yes ____ No ____

______________ ________________ __________ ____________________________________ Yes ____ No ____

Total ________________

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.

____________________________________________________________ ____________________

Applicant Date

____________________________________________________________ ____________________

Applicant Date

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.