2540-3 Color-of-Title Tax Levy and Payment Record

Form 2540-3
(February 2005)

FORM APPROVED
OMB NO. 1004-0029
Expires: October 31, 2006

UNITED STATES
DEPARTMENT OF THE INTERIOR
BUREAU O F LAND MANAGEMENT

COLOR - OF - TITLE TAX LEVY AND PAYMENT RECORD

Serial Number

Applicant's last name
Give legal description of land claimed
TOWNSHIP

RANGE

SECTION

SUBDIVISION

County

Meridian

TAX YEAR

(Continued on page 2)

PAYOR

State
AMOUNT OF TAX
LEVY
PAYMENT

TAX YEAR

AMOUNT OF TAX
LEVY
PAYMENT

PAYOR

I CERTIFY that the above listing is the correct tax levy and payment data as shown on the official tax records for the lands described.

(Signature)

(Position Title)

(Complete Address)

(Date)

Title 18 U.S.C. Section 1001 and Title 43 U.S.C. Section 1212, make it a crime for any person knowingly and willfully to make to any department or
agency of the United States any false, fictitious, or fraudulent statements or representations as to any matter within its jurisdiction.

INSTRUCTIONS
(REQUIRED FOR CLASS 2; REQUESTED FOR CLASS 1)
1. Type or print plainly in ink. Attach copy of Color-of-Title
Application (Form 2540-1).
2. Give information requested, in chronological order, for each year

from January 1, 1901 to date of filing application.
3. This form must be certified to by proper county official or abstractor,
e.g. tax assessor.

~~

(Continued on page 3)

(Form 2540-3, page 2)

NOTICES
The Privacy Act of 1974 and the regulations in 43 CFR 2.48(d) provide that you be furnished with the following
information required by this application.
AUTHORITY: 43 CFR part 2540.
PRINCIPAL PURPOSE: BLM uses this information to process this application.
ROUTINE USES: (1) The adjudication of the applicant's request. (2) Documentation for public information.
(3)Transfer to appropriate Federal agencies when concurrence is required prior to granting a right in use of public
lands or resources. (4)(5) Information from the record and/or the record will be transferred to appropriate Federal,
State, local or foreign agencies, when relevant to civil, criminal or regulatory investigations or prosecutions.
EFFECT OF NOT PROVIDING INFORMATION: Disclosure of the information is required to process the
application. If all the information is not provided, the application may be rejected.
The Paperwork Reduction Act of 1995 requires us to inform you that:
BLM collects this information to process your request for Federal lands under the provisions of the Color-of-Title
Regulations, found in 43 CFR Section 2540.
Information will be used to illustrate whether the applicant meets the requirements of the Act under which the
application is filed, see 43 CFR Part 2540, Subparts 2541-2547.
Response to this request is mandatory, see 43 CFR Subpart 2541.2.
BLM would like you to know that you do not have to respond to this or any other Federal agency-sponsored
information collection unless it displays a currently valid OMB control number.
BURDEN HOURS STATEMENT: Public reporting burden for this form is estimated to average 1 hour per
response, including the time for reviewing instructions, gathering, and maintaining data, and completing and
reviewing the form. Direct comments regarding the burden estimate or any other aspect of this form to U.S.
Department of the Interior, Bureau of Land Management (1004-0029), Bureau Information Collection Clearance
Officer (WO-630), 1849 C Street, N.W., Mail Stop 401 LS, Washington D.C. 20240.

______________________________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________________________

(Form 2540-3, page 3)