Form 5-5022 Navajo Partitioned Lands: Modification of Grazing Permit

Form 5-5022 UNITED STATES OMB No. 1076-0162

DEPARTMENT OF THE INTERIOR Expires: XX/XX/20XX

BUREAU OF INDIAN AFFAIRS

NAVAJO PARTITIONED LANDS: MODIFICATION OF GRAZING PERMIT

Modification No. _________________

Range Unit No. ___________________________________ __________________________________________ Agency

Contract No. ______________________________________ ______________________________________________Reservation

Permittee_________________________________________ Date of permit ___________________________________________

BY AUTHORITY OF LAW and under the regulations (25 CFR 161), the above cited grazing permit, as previously modified by Modifications Numbers___________________________________________________________________________________, is hereby modified to include or exclude the lands on which fees are paid, or those under the on‑and‑off clause, described in detail on the attached schedule, which is made a part hereof; and to increase or decrease the number of livestock in accordance with the authorized stocking rate of the lands, and to change the terms of the permit as indicated below:

Area of tribal land From ___________________to __________________ acres

Area of owned land From ___________________to __________________ acres Area of leased land From ___________________to __________________ acres

TOTAL ON-AND-OFF From ___________________to __________________ acres

Number stock under permit (Exclusive of On‑and-Off) (C.H.S.) From ___________________to __________________ head Number stock under allottee use From ___________________to __________________ head Number stock under On‑and-off From ___________________to __________________ head TOTAL NUMBER STOCK From ___________________to __________________ head

THIS MODIFICATION becomes effective ________________________, and does not change any of the terms, conditions, or stipulations of the permit, except as specifically set forth herein.

IN WITNESS WHEREOF the said permittee has hereunto set his hand and seal this_____ day of ______________________

(Month, year)

WITNESSES:

_________________________________________ __________________________________________

(Permittee)

_________________________________________

APPROVED: BY: ___________________________________________________________

________________________________________________________

Authorized Bureau Official

Paperwork Reduction Act Statement: This information is collected to manage agriculture and grazing leases. The information is supplied by a respondent to obtain or retain a benefit, that is, 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: Information Collection Clearance Officer, Office of Regulatory Affairs – Indian Affairs, 1849 C Street, NW, Mail Stop 4141, Washington, DC 20240. Comments, including names and addresses of respondents, will be available for public review at this Indian Affairs address during business hours. 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.