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

Form 5-5521		OMB No. 1076-0157 Expires: ##/##/####
Range Unit: Permit C. #:	UNITED STATES DEPARTMENT OF THE INTERIOR BUREAU OF INDIAN AFFAIRS
CERTIFICATE AND APPLICATION FOR ON-AND-OFF GRAZING PERMIT

I/We, ______________________________________, Permittee(s) on Range Unit No. ____________ on the __________________________________ Reservation for the period beginning ___/___/______, and ending ___/___/______, DO HEREBY CERTIFY that the lands described on the table below are within or adjacent to the subject range unit, are owned or legally encumbered by me/us for grazing purposes, and will be used in common with the lands covered by my/our grazing permit on the cited range unit.

Land Type*	Land Description	Acreage	Lease Expiration

* Leased Indian Trust, Leased Federal/State, Leased Private, Permittee Owned.

Application is hereby made for an On‑and‑Off Grazing Permit in accordance with the regulations at 25 CFR 166.308. I/We certify that I/We have signed a Conservation Plan that includes the use of adjacent trust or non-trust rangelands not covered by the permit to be used in common with permitted lands.

IT IS UNDERSTOOD AND AGREED that the Superintendent will establish the maximum allowable stocking of all lands to be grazed in common on the range unit.

_______________________________________________(Permittee) ____/____/________

I approve this On-and-Off Grazing Permit and authorize the harvest of _______ AUMS from the above-described lands through: ____ an increase in the number of animals; ____ a longer season of use.

_______________________________________________(Superintendent) ____/____/________

Permittee Accept:

_______________________________________________(Permittee) ____/____/________

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.