BIA-DWP-Irr-103 Annual Assessment Waiver Application

Annual Assessment Waiver Application

OMB # 1076-0141

Expires MM/DD/YYYY

BIA-DWP-Irr-103

Rev. 2/2019

Irrigation Project: Irrigation Season:

Requester’s Name:

Legal description of the assessable acres I own/lease included under this waiver and service location:

Detailed description of deficiencies in BIA infrastructure preventing water delivery (attach additional pages as needed):

Signature: Date:

Purpose: This form is for requesting an Annual Assessment Waiver which if approved, allows the BIA to waive the annual operation and maintenance (O&M) assessment for 1 year. For your land to be granted an Annual Assessment Waiver, BIA must determine that our irrigation facilities are not capable of delivering adequate irrigation water to owned or leased land due to deficiencies in the irrigation infrastructure per 25 CFR §171.700. If approved, both parties agree that irrigation water will not be delivered in any quantity to the designated farm unit.

Instructions: Return this completed form to your local Irrigation Office. Please attach additional relevant documentation (including photos). This waiver application must be received by the Bureau of Indian Affairs prior to the bill due date for the year for which you are requesting the Annual Assessment Waiver. The Annual Assessment Waiver is only valid for the year in which it is granted. To obtain an Annual Assessment Waiver for a subsequent year, you must reapply. In order to be eligible for an Assessment Waiver, your Taxpayer Identification Number (SSN or EIN) must be on file.

Paperwork Reduction Act Notice of 1995 – This information is being collected as required under the Debt Collection Improvement Act of 1996 (DCIA) from individuals and organizations doing business with the government. Public reporting burden for this form is estimated to average one hour per response. Direct comments regarding the burden estimate or any other aspect of this form to the Information Collection Clearance Officer, Bureau of Indian Affairs, 1849 C Street, NW, MS-4141, Washington, DC 20240. Note: Comments, names and addresses of commentators 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. A federal agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The number and expiration date are displayed in the upper right corner of the form.

Privacy Act Statement – Authority: 25 U.S.C. 11; 31 U.S.C. 3711; and 25 CFR Part 171. This information is being collected from individuals and organizations doing business with the government as required under the Debt Collection Improvement Act of 1996 (DCIA). Purpose: The principal purpose for collecting this information is so the Bureau of Indian Affairs (BIA) can evaluate an applicant’s request for and approval of an Assessment Waiver. Information collected may also be used for billing, including collections, proper payment application and debt management actions. Routine Use: Information collected is used by the BIA for servicing the account if you own or lease land within an irrigation project where we assess fees and collect monies to administer, operate, maintain, and rehabilitate project facilities. This information may be disclosed to the U.S. Department of Justice or in a proceeding before a court or adjudicative body; Federal, state, local, or foreign law enforcement agency; Congress; U.S. Department of Treasury to effect payment; Federal agency for collecting a debt; and other Federal agencies to detect and eliminate fraud. The information may also be used for filing tax documents with the Internal Revenue Service (IRS) as required by law pursuant to the routine uses identified in the National Irrigation Information Management System (NIIMS), Interior, BIA-34. Disclosure: Voluntary; however, not doing so will prevent you from participating in or obtaining an Assessment Waiver.

BIA Signatures and Approvals

The BIA certifies that it is not capable of delivering adequate irrigation water to the farm unit identified above, due to deficiencies in BIA irrigation facilities. BIA also certifies that inadequate water supply due to natural conditions or climate is not justification for granting this Annual Assessment Waiver. (25 CFR 171§§ 700-720)

Project Manager/Engineer: Recommend Not Recommend

Signature: Date:

Regional Irrigation Engineer: Concur Non Concur

Signature: Date:

Agency Superintendent: Approve Disapprove

Signature: Date:

For Irrigation Project Processing Only

Please indicate reason for denial in Remarks below.

1. Posted in NIIMS? Yes No
   
   
   
   

2. Assigned Assessment Waiver Number:
   
   
   
   

3. Date Waiver Approved (Month Day, Year):
   
   
   
   

4. Unit/Serial Designation(s): Unit: Serial:

Unit Serial:

Unit Serial:

Unit Serial:

Unit Serial:

Unit Serial:

5. Maximo Asset ID(s):
   
   
   
   

6. Remarks:

Instructions for Assessment Waiver Package

Water User

Questions regarding this form should be directed to your local Irrigation Program staff. The completed form should be returned to the Irrigation Program staff along with supporting documentation. Please attach additional relevant documentation (including photos).

Irrigation Project Staff

The following items shall be included in the Assessment Waiver package.

1) A copy of the current O&M bill that clearly identifies the specific tract of land being considered for waiver, including the legal description and/or the Unit/Serial numbers for that tract.

2) A copy of a map and/or aerial photo that shows the location(s) of deficiencies hindering BIA’s ability to deliver service.

3) A copy of any documentation (current or prior year’s work order(s)) requests for infrastructure repair/ rehabilitation.

4) A copy of documentation from site visits, historic information and/or current photos, reports, etc.

5) A NIIMS print screen of any cancellation of prior year O&M assessments due to inability to deliver water.

6) A copy of previous Annual Assessment Waivers for this same tract.

This package must be compiled and sent to the Regional Irrigation Engineer for concurrence prior to final approval by the Agency Superintendent.

Page 1 of 3