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pdfOMB CONTROL NO.: 1006-0005
FORM 7-21PE
2010
DECLARATION OF PUBLIC ENTITY’S LANDHOLDINGS
For Certification and Reporting Requirements of the
Reclamation Reform Act of 1982
(7-09)
Districts must complete the “District Name” and “Date Received” boxes.
District Name:
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. Refer to the separate instructions that
accompany this form for special direction if your public entity indirectly holds land that is subject to the acreage limitation provisions. 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.
PUBLIC ENTITY INFORMATION
1(a). Name of public entity that holds land:
1(b). Employer Identification Number (EIN):
2(a). Public entity’s street address or rural route number, city, state, and zip code:
2(b). Mailing address if different from street address:
3(a). Telephone number where questions can be directed: (
)
3(b). Contact person:
4.
LAND YOUR PUBLIC ENTITY DIRECTLY OWNS THAT IS NOT OPERATED BY OR LEASED TO ANOTHER PARTY OR PARTIES
List all irrigable and/or irrigation land parcels westwide that are 100-percent owned by your public entity, including wholly owned legal entities, and not operated by a lessee, sublessee, or other operator.
Include land of this type that your public entity leases from another public entity here instead of including it under item 9. Identify such land as leased from a public entity after the legal description of the land
and include the name of that public entity. For additional space, use attachments.
(a)
District Name
(b)
Legal Description of Land Parcel(s) or
Assessor's Parcel Number
(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)
Other
(a)
District Name
7.
(c)
Number of Acres
TOTAL NUMBER OF ACRES YOUR PUBLIC ENTITY DIRECTLY OWNS THAT ARE NOT OPERATED BY A LESSEE, SUBLESSEE, OR OTHER OPERATOR:
LAND YOUR PUBLIC ENTITY DIRECTLY OWNS THAT IS OPERATED BY LESSEES OR OTHER OPERATORS
List all irrigable and/or irrigation land parcels westwide that are 100-percent owned by your public entity, including wholly owned legal entities, and operated by a lessee, sublessee, or other operator. Include
land of this type that your public entity leases from another public entity here instead of including it under item 9. Identify such land as leased from a public entity after the legal description of the land and
include the name of that public entity. For additional space, use Form 7-21CONT-O or your own similar continuation sheet.
Lessee/
Sublessee
5.
6.
(b)
Legal Description of Land Parcel(s) or Assessor's Parcel Number
(e) Lease Information
(d)
Identification of the Lessee, Sublessee, or Other Operator
(1)
Starting Date
(m/d/yr)
(2)
Ending Date
(m/d/yr)
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TOTAL NUMBER OF ACRES YOUR PUBLIC ENTITY DIRECTLY OWNS THAT ARE OPERATED BY A LESSEE, SUBLESSEE, OR OTHER OPERATOR:
1
(f)
Number of Acres
FORM 7-21PE (2010)
8.
PUBLIC ENTITY’S NAME:
9.
LAND YOUR PUBLIC ENTITY DIRECTLY LEASES FROM ANOTHER PARTY
List all irrigable and/or irrigation land parcels westwide that your public entity (or a legal entity in which your public entity has a 100-percent interest) leases from another party. Do
not include land your public entity leases from another public entity here. Such land is to be included under item 4 or 6, as appropriate. Include the sublessor ’s name and the
landowner’s name in column (d) if your public entity subleases from a sublessor. You must complete all columns except column (f) if your public entity subleases land parcels to
others and provide the sublessee ’s name and the landowner’s name in column (d). For additional space, use Form 7-21CONT-L or your own similar continuation sheet.
Other
(a)
District Name
Self
(b)
Legal Description of Land Parcel(s) or
Assessor's Parcel Number
(c)
Operated by:
(check one)
10.
11.
(d)
Landowner’s Name
(If the land has been subleased, see the above
instructions for other needed names.)
(e)
Lease Information
(2)
Ending Date
(m/d/yr)
(1)
Starting Date
(m/d/yr)
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(f)
Number of
Acres
TOTAL NUMBER OF ACRES YOUR PUBLIC ENTITY DIRECTLY LEASES:
□
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Does your public entity own or lease land through a legal entity that is wholly or partially owned by your public entity?
YES
NO
If the answer to item 11 is “YES,” you must also complete an “Attachment Sheet for Form 7-21PE” (Form 7-21PE-IND) for your public entity, and then proceed to items 12(a) and 12(b).
If the answer to item 11 is “NO,” proceed directly to items 12(a) and 12(b).
12(a). Is your public entity a department of the Federal government or a Federal agency?
□
YES
□
12(b). Is your public entity a public school district?
□
NO
YES
□
NO
If the answer to item 12(a) OR item 12(b) is “YES,” proceed to item 35. If the answers to item 12(a) AND item 12(b) are “NO,” proceed to item 13.
13.
LAND YOUR PUBLIC ENTITY BECAME THE OWNER OF OR BEGAN TO LEASE FROM ANOTHER PARTY AFTER DECEMBER 31, 2004
Did your public entity, or a legal entity in which your public entity has a 100-percent interest, become the owner of any of the land listed in items 4 and 6 or begin to lease from
another party any of the land listed in item 9 after December 31, 2004?
□
YES
□
NO
If “NO,” proceed to item 35. If “YES,” list the district(s) in which the land is located and the number of acres owned and/or leased in each district. NOTE: Use the effective date of the
lease agreement when determining whether the land was leased after December 31, 2004. If no effective date is specified in the lease, use the date the lease was signed.
(b) Number of Acres
(1) Owned (2) Leased
(a)
District Name
14.
TOTAL NUMBER OF ACRES FIRST OWNED OR LEASED AFTER DECEMBER 31, 2004:
2
(a)
(b)
(c) Legal Description of Land Parcel(s) or Assessor's
Parcel Number
(c) [item 14(a) + item 14(b)]:
FORM 7-21PE (2010)
15.
PUBLIC ENTITY’S NAME:
16.
Is any OR all of the land listed in item 13 currently used for OTHER PURPOSES than those listed below?
Corrections facilities
Hospitals or similar facilities
Facilities for agricultural research, instruction, or education
□
YES □ NO
Golf courses
Water treatment, waste
water facilities, or landfills
Wildlife mitigation refuges or habitats
Airports
Cemeteries
Parks or recreation areas/facilities
Residential assistance facilities
17.
If the answer to item 16 is “NO,” proceed to item 35. If the answer to item 16 is “YES,” provide the following information for the land that is used for other purposes and then proceed
to item 18(a).
(d) Check one:
(e)
(b)
(a)
(c)
Number
of
Legal Description of Land Parcel(s) or Assessor’s
(1)
(2)
District Name
Purpose for Which the Land Parcel is Used
Acres
Parcel Number(s)
Owned
Leased
18(a).
TOTAL NUMBER OF ACRES YOUR PUBLIC ENTITY DIRECTLY OWNS THAT IS USED FOR OTHER PURPOSES:
18(b).
TOTAL NUMBER OF ACRES YOUR PUBLIC ENTITY DIRECTLY LEASES FROM ANOTHER PARTY THAT IS USED FOR OTHER PURPOSES:
19.
20.
TOTAL NUMBER OF ACRES YOUR PUBLIC ENTITY DIRECTLY HOLDS (OWNS OR LEASES) THAT IS USED FOR OTHER PURPOSES:
For any or all of the land described in item 17, does your public entity receive:
YES
(a) Money (or its equivalent ) for any of the crop(s) produced?
(b) Money (or its equivalent ) for lease payments?
21.
NO
If the answers to items 20(a), 20(b), AND
20(c) are “NO,” proceed to item 34.
If the answer to item 20(a), 20(b), OR 20(c)
is “YES,” proceed to item 21.
(c) Any of the crop(s) produced, and all or some of the crop(s) is (are) then sold for money ( or its equivalent )?
ACREAGE LIMITATION STATUS OF YOUR PUBLIC ENTITY
Please check any one of the following boxes if the statement next to it applies to your public entity, and provide the requested information for that box.
□ My public entity holds or held land directly in a district after that district conformed to the discretionary provisions. Name of district that conformed: __________________________________________
□ My public entity submitted an irrevocable election. List one district where that irrevocable election was filed: ________________________________________________________________________
□ My public entity only indirectly holds or held land in a district after that district conformed to the discretionary provisions and my public entity currently submits or has submitted an RRA form to that district.
Name of district: ________________________________________________________________________________________________________________________________________________
If you checked a box because one of the above statements is applicable to your public entity, your public entity is subject to the discretionary provisions of Federal reclamation law. If none
of the above statements are applicable to your public entity, your entity is subject to the prior law provisions of Federal reclamation law. Proceed to item 22.
22(a). Did your public entity receive Reclamation irrigation water on or before October 1, 1981?
YES
NO
If "YES," proceed to item 22(b). If "NO," proceed to item 23.
22(b). If the answer to item 22(a) is "YES," in what district did your public entity receive Reclamation irrigation water:
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FORM 7-21PE (2010)
23. PUBLIC ENTITY’S NAME:
24.
YOUR PUBLIC ENTITY’S NONEXCESS LAND
The ownership entitlements for public entities are: (a) 640 acres if the public entity is subject to the discretionary provisions, or (b) 160 acres if the public entity is subject to the
prior law provisions. If the number of acres in item 18(a) does not exceed your public entity’s applicable ownership entitlement, proceed to item 28. If the number of acres in
item 18(a) exceeds your public entity’s applicable ownership entitlement, list the owned land from item 17 that will be designated as nonexcess by completing items 24(a)
through 24(c) below. Columns 24(d) and 24(e) are completed only if the land in question is located in a district that has Class 1 equivalency factors and your public entity is
subject to the discretionary provisions. Refer to the separate instructions for further guidance regarding the use of columns (d) and (e).
(a)
District Name
25.
26.
27.
(b)
Legal Description of Land Parcel(s) or Assessor’s Parcel Number(s)
(c)
Actual Acres
(d)
Class 1
Equivalency
Factor
(e)
Class 1
Equivalent
Acres
TOTAL NONEXCESS ACRES (use the workspace provided in the instructions for item 25 to calculate this total):
YOUR PUBLIC ENTITY’S EXCESS LAND
List the owned land from item 17 that will be designated as excess land by completing items 26(a) through 26(d) below. If Reclamation irrigation water is being delivered to
any of the land, list the reason in the last column.
(d)
(b)
(c)
(a)
Legal Description of Land Parcel(s) or
Number of Actual Reason Land is Receiving Reclamation Irrigation
District Name
Water (if applicable)
Assessor's Parcel Number(s)
Excess Acres
TOTAL NUMBER OF ACTUAL EXCESS ACRES:
4
FORM 7-21PE (2010)
28. PUBLIC ENTITY’S NAME:
YOUR PUBLIC ENTITY’S NONFULL-COST LAND
29.
The nonfull-cost entitlements for public entities are: (a) 320 acres if the public entity is subject to the discretionary provisions and received Reclamation irrigation water on or before
October 1, 1981; or (b) zero acres if the public entity is subject to the discretionary provisions and did not receive Reclamation irrigation water on or before October 1, 1981;
or (c) 160 acres if the public entity is subject to the prior law provisions. If the number of acres in item 19 does not exceed your public entity’s applicable nonfull-cost entitlement,
proceed to item 35. If the number of acres in item 19 exceeds your public entity’s applicable nonfull-cost entitlement, list the land held by your public entity (from item 17) that will
be selected as nonfull-cost land by completing items 29(a) through 29(c) below. Columns 29(d) and 29(e) are completed only if the land in question is located in a district that has
Class 1 equivalency factors and your public entity is subject to the discretionary provisions. Refer to the separate instructions for further guidance regarding the use of
columns (d) and (e).
(a)
District Name
30.
31.
32.
33.
34.
(b)
Legal Description of Land Parcel(s) or Assessor’s Parcel Number(s)
(c)
Actual Acres
(d)
Class 1
Equivalency
Factor
(e)
Class 1
Equivalent
Acres
TOTAL NONFULL-COST ACRES TO RECEIVE WATER AT NONFULL-COST RATES (use the workspace provided in the instructions for item 30 to calculate this total):
YOUR PUBLIC ENTITY’S ACTUAL ACRES THAT ARE NOT RECEIVING RECLAMATION IRRIGATION WATER
List the land held by your public entity (from item 17) that is not receiving Reclamation irrigation water. Place a check mark in column (c) if the land is not currently being irrigated.
Place a check mark in column (d) if the land is receiving water from a source other than a Reclamation irrigation project. For additional space, use attachments.
(d)
(e)
(a)
(c)
(b)
Receiving
Number of Actual
District Name
Not Irrigated
Legal Description of Land or Assessor’s Parcel Number
Nonproject Water
Acres
TOTAL NUMBER OF ACTUAL ACRES THAT ARE NOT RECEIVING RECLAMATION IRRIGATION WATER:
YOUR PUBLIC ENTITY’S FULL-COST LAND
List the land held by your public entity (from item 17) for which the full-cost rate will be paid by completing items 33(a) through 33(c) below.
(b)
(a)
Legal Description of Land Parcel(s) or
District Name
Assessor's Parcel Number(s)
TOTAL NUMBER OF ACRES FOR WHICH THE FULL-COST RATE WILL BE PAID:
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(c)
Number of Actual
Full-Cost Acres
FORM 7-21PE (2010)
35. PUBLIC ENTITY’S NAME:
LANDHOLDINGS SUMMARY
TOTAL
36. DISTRICT NAME(S):
37.
Total directly owned acres not operated by a lessee or other operator:
(Obtain this information from item 4.)
38.
Total directly owned acres operated by a lessee or other operator:
(Obtain this information from item 6.)
39. Total directly owned acres used for other purposes and for which
revenue (or its equivalent) is received:
(Obtain this information from item 17.)
40. Total directly leased acres used for other purposes and for which
revenue (or its equivalent) is received:
(Obtain this information from item 17.)
Total excess acres:
41.
(Obtain this information from item 26.)
Total full-cost acres:
42.
(Obtain this information from item 33.)
43.
Attention: This declaration must be signed and dated. Read the following
paragraphs before signing.
SIGNATURE(S)
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 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.
Signature of Officer or Authorized Agent of Your Public Entity
I attest that the information provided herein is true, accurate, and complete to the best of my 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 further attest that any leases of land receiving irrigation water to which my
public entity is 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 have written approval from the Bureau of Reclamation.
Date
Office Held
This declaration is required by Public Law 97-293. Failure to declare can result in prosecution and/or loss of water deliveries from Federal reclamation projects. Information obtained in this declaration 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(S).
6
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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Number of
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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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| File Type | application/pdf |
| Author | shartman |
| File Modified | 2009-04-16 |
| File Created | 2009-04-16 |