Form 7-2180 Certification of Individual's Landholdings

OMB CONTROL NO.: 1006-0005

FORM 7-2180
2012

Districts must complete the “District Name” and “Date Received” boxes.

District Name:

CERTIFICATION OF INDIVIDUAL’S LANDHOLDINGS
(Discretionary Provisions)

(7-11)

DATE RECEIVED:

BUREAU OF RECLAMATION

Do not use this form after December 31, 2012. 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.

LANDHOLDER INFORMATION
1.

Landholder name:

2.

Marital status:

3.

Spouse name:

4(a). Landholder’s street address or rural route number, city, state, and zip code:

4(b). Mailing address if different from street address:

5(a). Telephone number where questions can be directed: (

5(b). Contact person:

6.

(a)
Name

7.

)

List all entities in which you, your spouse, if you are married, and/or your dependents hold irrigable and/or irrigation land. Include only those entities that directly own or lease land in
which you, your spouse, and/or your dependents own 100-percent interest. List the names of your dependents if they hold land in their own names or other names in which you or your
spouse hold land. Do not list trusts and estates of which you are a beneficiary. Instead, list such trusts and estates in item 15. For purposes of determining total landholdings, land
listed here must be listed again in the appropriate section of this form. All trusts and estates must complete Form 7-21TRUST. For additional space, use attachments.
(b)
Employer Identification Number
(for entities only)

(c)
(d)
(e)
Legal Description of Land Parcel(s) or
State(s) or Country(ies)
Number of Acres
Assessor's Parcel Number(s)
(where established,
(for entities only)
(List land held in other names and entities.)
if an entity)

Check the box that indicates your citizenship status. If you are a nonresident alien,
also enter the country of which you are a citizen.

Self
U.S. Citizen
Resident Alien
Nonresident Alien

8.

□

Are you claimed as a dependent within the meaning of the Internal Revenue Code?
(Dependents must be included on their parents’ or legal guardians’ Form 7-2180.)
1

Yes

□

No

Spouse

(f) Status
Prior Law

Country of Citizenship

Discretonary

FORM 7-2180 (2012)
9. LANDHOLDER’S NAME:
10.

LAND YOU DIRECTLY OWN

List all irrigable and/or irrigation land parcels westwide that are 100-percent owned by you. Include land directly owned by any entity in which you own 100-percent interest. Include land you lease from a
public entity here instead of including it under item 13. Identify such land as leased from a public entity and include the name of that public entity after the legal description of the land. For additional space,
use Form 7-21CONT-O or your own similar continuation sheet.
Lease Information

Other

Lessee/
Sublessee

(c) Operated by:
(check one)

Self

(a)
District Name

(b)
Legal Description of Land Parcel(s) or
Assessor's Parcel Number(s)
(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.)

(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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TOTAL NUMBER OF ACRES YOU DIRECTLY OWN
2

(g)
Number of
Acres

FORM 7-2180 (2012)
12. LANDHOLDER’S NAME:
13.

LAND YOU DIRECTLY LEASE FROM ANOTHER PARTY
List all irrigable and/or irrigation land parcels westwide that you lease from another party. Include land directly leased by any entity in which you own 100-percent interest. Do not include land you lease from a
public entity here. Such land is to be included under item 10. Include the sublessor’s name and the landowner’s name in column (d) if you sublease from a sublessor. Include the farm operator's name in
column (d) if the land is operated by a farm operator. You must complete all columns except column (g) if you sublease 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.

(b)
Legal Description of Land Parcel(s) or
Assessor's Parcel Number(s)

14.

Other

(a)
District Name

Self

(c) Operated by:
(check one)

Lease Information

(d)
Landowner's Name
(If the land has been subleased or is
operated by a farm operator, see the
above instructions for other needed names.)

(e)
Starting Date
(m/d/yr)

(f)
Ending
Date
(m/d/yr)

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(g)
Number of
Acres

TOTAL NUMBER OF ACRES YOU DIRECTLY LEASE
LAND YOU INDIRECTLY OWN OR LEASE THROUGH OTHER ENTITIES

15.

List all entities that hold irrigable and/or irrigation land in which you own a part (less than 100-percent interest, and all trusts and estates in which you own up to and including 100-percent interest. Do not
include land directly held by any entity in which you own 100-percent interest. Instead, include that land in item 10 or item 13 as appropriate. Include land indirectly held by any entity in which you own
100-percent interest. You will have to enter an entity’s name on more than one line if it holds irrigable and/or irrigation land in more than one district. Obtain a copy of the entity’s completed Form 7-2181 or
Form 7-2191, or a copy of the trust’s or estate’s completed Form 7-21TRUST to ensure the accuracy of the information you provide. For land held by a dependent, include the name of the dependent after
the name of the entity. For additional space, use Form 7-21CONT-I or your own similar continuation sheet.

(a)
District Name

16.
17.

(b)
Name of Entity

(d)
Percentage
of Interest
You Own in
Each Entity

(c)
Entity Employer
Identification Number

(e)
Number of
Acres
Owned by
the Entity
in Each
District

(f)
Owned
Acreage
Attributable
to Your
Interest in
the Entity
(d X e)

(g)
Number of
Acres
Leased by
the Entity in
Each District

(h)
Double-Counting
Adjustments
(1)
Owned
Acres
in (g)

TOTAL NUMBER OF ACRES YOU INDIRECTLY OWN
TOTAL NUMBER OF ACRES YOU INDIRECTLY LEASE
3

(2)
Adjusted
Acres
[g minus h(1)]

(i)
Leased
Acreage
Attributable
to Your
Interest in
the Entity

FORM 7-2180 (2012)
18. LANDHOLDER’S NAME:
LANDHOLDINGS SUMMARY
Circle the district at which the original form is filed if you are a multidistrict landholder.

19. DISTRICT NAME(S):

TOTAL

20. Total directly owned acres:
21. Total indirectly owned acres:
*

22. Total owned acres (item 20 plus item 21):
23. Total directly leased acres:
24. Total indirectly leased acres:
25. Total leased acres (item 23 plus item 24) :

**

26. Total owned and leased acres (item 22 plus item 25):

* NOTE: You need to complete Form 7-21XS if this total exceeds your ownership entitlement. If some of this land was designated as excess by the seller and you purchased it without sales price
approval by Reclamation, you must designate that land as excess on Form 7-21XS, even if you do not exceed your ownership entitlement. You must complete a Form 7-21XS if you own any
land designated as excess for any reason (for example, you designated involuntarily acquired land as excess).
** NOTE: You need to complete Form 7-21FC if this total exceeds your nonfull-cost entitlement AND you directly or indirectly lease land.

27. Acreage limitation status – Please check one of the following boxes and provide the requested information for that box:

□

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28.

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:
_______________________________________________________________ (Not applicable to nonresident aliens or spouses who are both nonresident aliens.)
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, my spouse, or we only indirectly hold(s) or held land in a district after that district conformed to the discretionary provisions and I, my spouse, or we currently submit or have submitted a
“Certification of Individual’s Landholding” (Form 7-2180) to that district. Name of district: _______________________________________________________________________
(Not applicable to nonresident aliens or spouses who are both nonresident aliens.)
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: ____________________________________________________________________________________________________________________________

SIGNATURE(S)
Your spouse must sign this form if you are 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 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 all districts
named 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 crops leases which cannot exceed 25 years and
must 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, and any
dependents (if applicable), whether held directly or indirectly, have been identified on this form.

Landholder’s Signature

Date

Spouse's Signature

Date

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 certification 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).
4

OMB CONTROL NO.: 1006-0005

CONTINUATION SHEET FOR DIRECTLY OWNED LAND
For Certification and Reporting Requirements of the
Reclamation Reform Act of 1982

FORM 7-21CONT-O
2012
(7-11)
BUREAU OF RECLAMATION

Do not use this form after December 31, 2012. 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 (2012)
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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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
2012

CONTINUATION SHEET FOR DIRECTLY LEASED LAND
For Certification and Reporting Requirements of the Reclamation Reform Act of 1982

(7-11)
BUREAU OF RECLAMATION

Do not use this form after December 31, 2012. 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 (2012)
LANDHOLDER’S NAME:
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.]

2

Lease Information
(e)
Starting Date
(m/d/yr)

(f)
Ending Date
(m/d/yr)

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(g)
Number of
Acres

OMB CONTROL NO.: 1006-0005

CONTINUATION SHEET FOR INDIRECTLY HELD LAND
For Certification and Reporting Requirements of the Reclamation Reform Act of 1982

FORM 7-21CONT-I
2012
(7-11)
BUREAU OF RECLAMATION

Do not use this form after December 31, 2012. 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 indirectly held
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 (j). 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 INDIRECTLY HOLDS THROUGH OTHER ENTITIES

(a)
District Name

(b)
Name of Entity

(c)
Entity Employer
Identification Number

(f)
(d)
Owned
(e)
(g)
Percentage
Acreage
Number of
Number of
of Interest
Attributable to
Acres
Acres
the
the
Owned by
Leased by
Landholder
Landholder’s
the Entity in
the Entity in
Owns in
Interest in the
Each District
Each District
Each Entity
Entity
(d X e)

1

(h)
Double-Counting
Adjustments
(1)
Owned
Acres
in (g)

(j)
(i)
Leased
PRIOR
Acreage
LAW ONLY
Attributable to Was Owned
(2)
the
Land Acquired
Adjusted
Landholder’s After 12/06/79?
Acres
Interest in the
[g minus h(1)]
Entity
YES
NO

FORM 7-21CONT-I (2012)
LANDHOLDER’S NAME:
THIS FORM IS A CONTINUATION OF FORM 7-21__________________ DATED _______________________
LAND THE LANDHOLDER INDIRECTLY HOLDS THROUGH OTHER ENTITIES

(a)
District Name

(b)
Name of Entity

(c)
Entity Employer
Identification Number

(f)
(d)
Owned Acreage
(e)
(g)
Percentage
Attributable
Number of
Number of
of Interest
to the
Acres
Acres Leased
the
Landholder’s by the Entity
Owned by
Landholder
the Entity in Interest in the
in Each
Owns in
Entity
Each District
District
Each Entity
(d X e)

2

(h)
Double-Counting
Adjustments
(1)
Owned
Acres
in (g)

(i)
Leased
Acreage
Attributable to
the
(2)
Landholder’s
Adjusted
Interest in the
Acres
Entity
[g minus h(1)]

(j)
PRIOR LAW
ONLY
Was Owned
Land Acquired
After 12/06/79?

YES

NO