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pdfOMB CONTROL NO.: 1006-0005
FORM 7-2180EZ
2010
Districts must complete the “District Name” and “Date Received” boxes.
“EZ” CERTIFICATION OF INDIVIDUAL’S LANDHOLDINGS District Name:
(Discretionary Provisions)
(7-09)
DATE RECEIVED:
BUREAU OF RECLAMATION
Do not use this form after December 31, 2010. It is important that you read the separate instructions that accompany this form before completing it. If you did not receive these
instructions, please contact your district office. Type or print in ink. Date and initial crossouts and corrections. Visit www.usbr.gov/rra for more information.
You may use this form ONLY IF: (1) All your landholdings subject to acreage limitation provisions are located in only one district, (2) your landholdings subject to acreage limitation provisions total 960 acres or less, (3) you
directly hold all your landholdings (that is, the land is not owned or leased through any type of legal entity, such as a corporation, trust, estate, or partnership, or in the names of your children or other dependents), (4) you are not
a dependent, (5) either you or your spouse (if married) is a U.S. citizen or resident alien, AND (6) you are subject to the discretionary provisions of the Reclamation Reform Act of 1982. If you do not meet all of these
requirements, do not complete this form. Please contact your district office to obtain the proper form.
1.
2.
Landholder name:
Marital status:
3.
Spouse name:
4(a). Landholder’s street address or rural route number, city, state, and zip code:
5(a).
6.
7.
4(b). Mailing address if different from street address:
Telephone number where questions can be directed:
(
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5(b). Contact person:
Self
Check the box that indicates your citizenship status. If you are a nonresident alien, also
enter the country of which you are a citizen. You are completing the wrong form if you U.S. Citizen
Resident Alien
and your spouse, if married, are nonresident aliens. The appropriate form(s) can be
obtained from your district office.
Nonresident Alien
LAND YOU OWN
Spouse
Country of Citizenship
List all irrigable and/or irrigation land parcels that are 100-percent owned by you. Include land you lease from a public entity here. Identify such land as leased from a public entity and include the
name of that public entity after the legal description of the land. You are completing the wrong form if you own land (but not 100-percent interest), or own any land through an entity. The proper
form(s) can be obtained from your district office. For additional space, use Form 7-21CONT-O or your own similar continuation sheet.
(c)
Identification of Lessee, Sublessee, or
Other Operator
Other
Lessee/
Sublessee
(There is space to list four different parcels [one per line]
if they all are operated by the same natural person or entity)
(b) Operated by:
(check one)
Self
(a)
Legal Description of Land Parcel(s) or Assessor’s Parcel Number(s)
Lease Information
(d)
Starting Date
(m/d/yr)
(e)
Ending Date
(m/d/yr)
Name:
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Address:
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TOTAL NUMBER OF ACRES YOU OWN
8.
1
(f)
Number of
Acres
FORM 7-2180EZ (2010)
9.
LANDHOLDER’S NAME:
10.
LAND YOU LEASE FROM ANOTHER PARTY
List all irrigable and/or irrigation land parcels that you lease from another party. Do not include land you lease from a public entity here. Such land is to be included under item 7. Include the sublessor’s name
and the landowner’s name in column (c) if you sublease from a sublessor. Include the farm operator's name in column (c) if the land is operated by a farm operator. You must complete all columns except
column (f) if you sublease land parcels to others and provide the sublessee’s name and the landowner’s name in column (c). You are completing the wrong form if you lease land through an entity. The
proper form(s) can be obtained from your district office. For additional space, use Form 7-21CONT-L or your own similar continuation sheet.
(b) Operated by:
(check one)
(c)
Landowner’s Name
(If the land has been subleased or is
operated by a farm operator, see the
above instructions for other needed names.)
Other
Self
(a)
Legal Description of Land Parcel(s) or
Assessor's Parcel Number(s)
11.
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(d)
Starting Date
(m/d/yr)
(e)
Ending Date
(m/d/yr)
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(f)
Number of
Acres
TOTAL NUMBER OF ACRES YOU LEASE
12.
13.
Lease Information
TOTAL OWNED AND LEASED ACRES (item 8 plus item 11)
Acreage limitation status – Please check one of the following boxes and provide the requested information for that box:
I, my spouse, or we hold(s) or held land directly in a district after that district conformed to the discretionary provisions. Name of district that conformed: _________________________________________
I, my spouse, or we submitted an irrevocable election to conform to the discretionary provisions. List one district where that irrevocable election was filed: ______________________________________
I or my spouse was married to a person who was subject to the discretionary provisions. Name of that person and district: _____________________________________________________
Other, please describe: ___________________________________________________________________________________________________________________________________
14.
SIGNATURE(S)
Your spouse must sign this form, if married. This requirement applies even if the land is not jointly held. You may use a written spousal signature authorization to permit one spouse to sign for the couple.
Attention: This certificate must be signed and dated. Read the following
paragraphs before signing.
Under the provisions of 18 U.S.C. 1001, it is a crime punishable by 5 years imprisonment or a fine of
up to $10,000, or both, for any person to knowingly and willfully submit or cause to be submitted to
any agency of the United States any false or fraudulent statement(s) as to any matter within the
Landholder’s Signature
Date
agency’s jurisdiction. False statements by the landowner or lessee will also result in loss of eligibility.
Eligibility can only be regained upon the approval of the Commissioner
I (we) attest that the information provided herein is true, accurate, and complete to the best of my
(our) knowledge and agree that any change in the landholdings information contained in this
certification will be provided verbally to this district within 30 calendar days of such change, and that
new forms will be submitted within 60 calendar days of such change. I (we) further attest that any
leases of land receiving irrigation water to which I am (we are) a party are in writing and have terms
that do not exceed 10 years, except perennial crop leases which cannot exceed 25 years and must
Spouse’s Signature
Date
have written approval from the Bureau of Reclamation. I (we) also attest that, in my (our) best
judgment, the rent paid on any land leased by or from me (us) that is receiving irrigation water
reflects the reasonable value of the irrigation water to the productivity of the land. In addition, I (we)
attest that all landholdings of both spouses, if married, are held directly and have been identified on
this form.
This certification is required by Public Law 97-293. Failure to certify can result in prosecution and/or loss of water deliveries from Federal reclamation projects. Information obtained in this certificate is protected by the Privacy Act of 1974, system of
records notice INTERIOR/WBR-31, and will be used to administer the acreage limitation provisions of Federal reclamation law. The Secretary of the Interior or the district may require additional information in order to administer these laws. The
Secretary may also require a copy of your lease(s).
PLEASE RETURN THIS FORM TO THE APPROPRIATE DISTRICT OFFICE.
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OMB CONTROL NO.: 1006-0005
FORM 7-21CONT-O
2010
CONTINUATION SHEET FOR DIRECTLY OWNED LAND
For Certification and Reporting Requirements of the Reclamation Reform Act of 1982
(7-09)
BUREAU OF RECLAMATION
Do not use this form after December 31, 2010. Refer to the instructions of the form for which you are preparing this continuation sheet. You may use this continuation sheet for additional space when listing
directly owned land, or you may use your own similar continuation sheet. Type or print in ink. Date and initial crossouts and corrections. Only landholders subject to prior law provisions should complete
column (h). Use as many of these continuation sheets as necessary. Visit www.usbr.gov/rra for more information.
LANDHOLDER NAME(S):
THIS FORM IS A CONTINUATION OF FORM 7-21__________________ DATED _______________________
LAND THE LANDHOLDER DIRECTLY OWNS
Other
Lessee/
Sublessee
(There is space to list four different parcels
[one parcel per line] if they all are operated by the
same natural person or entity in the same district.)
(c)
Operated by:
(check one)
Self
(a)
District Name
(b)
Legal Description of Land Parcel(s) or
Assessor's Parcel Number(s)
Lease Information
(d)
Identification of the Lessee, Sublessee, or Other Operator
(e)
Starting Date
(m/d/yr)
(f)
Ending Date
(m/d/yr)
Name:
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Address:
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(g)
Number
of
Acres
(h)
PRIOR LAW
ONLY
Was Land
Acquired After
12/06/79?
YES
NO
FORM 7-21CONT-O (2010)
LANDHOLDER NAME(S):
THIS FORM IS A CONTINUATION OF FORM 7-21__________________ DATED _______________________
LAND THE LANDHOLDER DIRECTLY OWNS
Other
Lessee/
Sublessee
(There is space to list four different parcels
[one parcel per line] if they all are operated by the
same natural person or entity in the same district.)
Self
(a)
District Name
(b)
Legal Description of Land Parcel(s) or
Assessor's Parcel Number(s)
(c)
Operated by:
(check one)
Lease Information
(d)
Identification of the Lessee, Sublessee, or Other Operator
(e)
Starting Date
(m/d/yr)
(f)
Ending Date
(m/d/yr)
Name:
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Address:
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Telephone:
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(g)
Number
of
Acres
(h)
PRIOR LAW
ONLY
Was Land
Acquired After
12/06/79?
YES
NO
OMB CONTROL NO.: 1006-0005
FORM 7-21CONT-L
2010
CONTINUATION SHEET FOR DIRECTLY LEASED LAND
For Certification and Reporting Requirements of the Reclamation Reform Act of 1982
(7-09)
BUREAU OF RECLAMATION
Do not use this form after December 31, 2010. Refer to the instructions of the form for which you are preparing this continuation sheet. You may use this continuation sheet for additional space when listing
directly leased land, or you may use your own similar continuation sheet. Type or print in ink. Date and initial crossouts and corrections. Use as many of these continuation sheets as necessary. Visit
www.usbr.gov/rra for more information.
LANDHOLDER NAME(S):
THIS FORM IS A CONTINUATION OF FORM 7-21__________________ DATED _______________________
LAND THE LANDHOLDER DIRECTLY LEASES FROM ANOTHER PARTY
Other
(c) Operated by:
(check one)
Self
(a)
District Name
(b)
Legal Description of Land Parcel(s) or
Assessor's Parcel Number(s)
(d)
Landowner’s Name
[If the land has been subleased or is
operated by a farm operator, see the
instructions to the form for other needed names.]
1
Lease Information
(e)
Starting Date
(m/d/yr)
(f)
Ending Date
(m/d/yr)
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(g)
Number of
Acres
FORM 7-21CONT-L (2010)
LANDHOLDER’S NAME:
THIS FORM IS A CONTINUATION OF FORM 7-21__________________ DATED _______________________
LAND THE LANDHOLDER DIRECTLY LEASES FROM ANOTHER PARTY
Other
Self
(a)
District Name
(b)
Legal Description of Land Parcel(s) or
Assessor's Parcel Number(s)
(c) Operated by:
(check one)
(d)
Landowner’s Name
[If the land has been subleased or is
operated by a farm operator, see the
instructions to the form for other needed names.]
2
Lease Information
(e)
Starting Date
(m/d/yr)
(f)
Ending Date
(m/d/yr)
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(g)
Number of
Acres
| File Type | application/pdf |
| Author | shartman |
| File Modified | 2009-04-16 |
| File Created | 2009-04-16 |