Form 7-2191 Report of Entity's Landholdings

OMB CONTROL NO.: 1006-0005

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

FORM 7-2191
2012

District Name:

REPORT OF ENTITY'S LANDHOLDINGS
(Prior Law 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.

Entity name:

2(a).

Entity type (check one):

2(b).

If your entity is a religious or charitable organization that does not meet the RRA section 219 criteria, proceed to item 3(a).

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Corporation

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Partnership

□ Joint tenancy or tenancy-in-common □ Other: ____________________________________________

If you checked “Other” in item 2(a), how is your entity taxed by the Internal Revenue Service (check one box):

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As a corporation

□ As a partnership

3(a). Entity’s street address or rural route number, city, state, and ZIP code:

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

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

4(b). Contact person:

)

5.

Name of state(s) or country(ies) where entity is established or registered (if applicable):

6.
7.

Employer Identification Number (EIN):
Subsidiaries that are wholly owned by your entity that hold all of the irrigable and/or irrigation land. For additional space, use attachments. For purposes of determining total landholdings, land listed here must be
listed again in the appropriate section of this form. Note: You must describe and submit your organizational structure with this form.

Name:

Status:

EIN:

Entity Type:

Name:

Status:

EIN:

Entity Type:

Name:

Status:

EIN:

Entity Type:

8.
9.

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

(b)
State(s) or Country(ies) Where
Subsidiary is Established

(a)
Subsidiary

□

Is your entity owned (directly or indirectly) by, or does it benefit, 26 or more natural persons?

Yes

□

(d)
Number of Acres

No

List all of the part owners if the answer to question 8 is “NO.”
List the part owners whose interest in your entity results in an attribution of more than 40 acres if the answer to question 8 is “YES.” For additional space, use attachments.
(a)
Part Owner

(b)
EIN

1

(c) Status
Prior Law

Discretionary

(d)
Percentage of
Interest Owned

FORM 7-2191 (2012)
10. ENTITY’S NAME:
11.

LAND YOUR ENTITY DIRECTLY OWNS

List all irrigable and/or irrigation land parcels westwide that are 100-percent owned by your entity. Include land directly owned by your entity’s wholly owned subsidiaries. Include land your entity leases from
a public entity here instead of including it under item 14. 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.

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

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

Name:

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Address:

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

TOTAL NUMBER OF ACRES YOUR ENTITY DIRECTLY OWNS
2

(g)
Number of
Acres

(h)
Was Land
Acquired After
12/06/79?
YES

NO

FORM 7-2191 (2012)
13. ENTITY’S NAME:
14.

LAND YOUR ENTITY DIRECTLY LEASES FROM ANOTHER PARTY
List all irrigable and/or irrigation land parcels westwide that your entity leases from another party. Include land directly leased by your entity’s wholly owned subsidiaries. Do not include land your entity leases
from a public entity here. Such land is to be included under item 11. Include the sublessor’s name and the landowner’s name in column (d) if your entity subleases 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 your 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.
(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)

Other

Self

(a)
District Name

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

(c)
Operated by:
(check one)

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

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

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(g)
Number
of Acres

TOTAL NUMBER OF ACRES YOUR ENTITY DIRECTLY LEASES
LAND YOUR ENTITY INDIRECTLY OWNS OR LEASES THROUGH OTHER ENTITIES

15.
16.

List all entities that hold irrigable and/or irrigation land in which your entity owns a part (less than 100-percent) interest, and all trusts and estates in which your entity owns up to and including 100-percent
interest. Do not include land directly held by your entity’s wholly owned subsidiaries. Instead, include that land in item 11 or item 14 as appropriate. Include land indirectly held by your entity’s wholly
owned subsidiaries. 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 other 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 additional space, use Form 7-21CONT-I or your
own similar continuation sheet.

(a)
District Name

17.
18.

(b)
Name of Other Entity

(c)
Other Entity Employer
Identification Number

(d)
Percentage of
Interest Your
Entity Owns
in Each Other
Entity

(f)
(g)
(e)
Number of Owned Acreage Number of
Attributable
Acres
Acres
Owned by to Your Entity's Leased by
Interest in the
the Other
the Other
Other Entity
Entity in
Entity in
(d X e)
Each District
Each District

TOTAL NUMBER OF ACRES YOUR ENTITY INDIRECTLY OWNS
TOTAL NUMBER OF ACRES YOUR ENTITY INDIRECTLY LEASES
3

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

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

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

YES

NO

FORM 7-2191 (2012)
19. ENTITY’S NAME:
LANDHOLDINGS SUMMARY
Circle the district at which the original form is filed if your entity is a multidistrict landholder.

20. DISTRICT NAME(S):

TOTAL

21. Total directly owned acres:
22. Total indirectly owned acres:
23. Total owned acres (item 21 plus item 22):

*

24. Total directly leased acres:
25. Total indirectly leased acres:
26. Total leased acres (item 24 plus item 25):
27. Total owned and leased acres (item 23 plus item 26):

**
*NOTE: You need to complete Form 7-21XS for your entity if this total exceeds your entity’s ownership entitlement. If some of this land was designated as excess by the seller and your entity
purchased it without sales price approval by Reclamation, you must designate that land as excess on Form 7-21XS, even if your entity does not exceed its ownership entitlement. Your
entity must complete a Form 7-21XS if your entity owns any land designated as excess for any reason (for example, your entity designated involuntarily acquired land as excess).

**NOTE: You need to complete Form 7-21FC for your entity if this total exceeds your entity’s nonfull-cost entitlement AND your entity directly or indirectly leases land.

28. Acreage limitation status – Please check all of the following boxes that apply to you entity:

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□
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Your entity does NOT hold and has NEVER held land directly in a district after that district conformed to the discretionary provisions. (Not applicable to foreign entities.)
Your entity has NEVER submitted an irrevocable election to conform to the discretionary provisions.
Your entity only indirectly holds or held land in a district after that district conformed to the discretionary provisions and your entity has NEVER submitted a “Certification of Entity’s Landholdings”
(Form 7-2181) to that district. (Not applicable to foreign entities.)

29.

SIGNATURE(S)
All partners, joint tenants, or co-tenants must sign this form unless they have provided a written signature authorization allowing one natural person to sign for your entity.

Attention: This report 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.

Signature of Officer or Authorized Agent

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 report 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 my
(our) entity is 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.
This report is required by Public Law 97-293. Failure to report can result in prosecution and/or loss of water
deliveries from Federal reclamation projects. Information obtained in this report 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).

Other Required Signature

Date

Other Required Signature

Date

Other Required Signature

Date

Other Required Signature

Date

Date

Office Held

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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(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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(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