Form 5-5521 Certificate and Application for On-and-Off Grazing Permi

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

DEPARTMENT OF THE INTERIOR Expires: __________

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 UNDERSTOOD 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 and permits. The information is supplied by a respondent to obtain or retain a benefit, that is, a lease or a permit. 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 - Indian Affairs, Office of Regulatory Affairs and Collaborative Action, 1849 C Street NW, Mail Stop 4141 MIB, Washington, DC 20240. Before including your address, phone number, e-mail address, or other personal identifying information in your comment, you should be aware that your entire comment—including your personal identifying information—may be made publicly available at any time. 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.