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pdfOMB CONTROL NO.: 1006-0005
FORM 7-21TRUST
2012
DECLARATION OF TRUST'S OR ESTATE'S LANDHOLDINGS Districts must complete the “District Name” and “Date Received” boxes.
District Name:
For Certification and Reporting Requirements of the
Reclamation Reform Act of 1982
DATE RECEIVED:
(7-11)
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. Individual landholders and entity landholders (other than trusts or estates) cannot use this form; proper forms can be obtained from your district office. Type or print in ink.
Date and initial crossouts and corrections. Visit www.usbr.gov/rra for more information.
TRUST OR ESTATE INFORMATION
1.
Trust or estate name:
2(a). Trust or estate (check one):
2(b). Employer Identification Number (EIN):
□ Trust □ Estate
3.
TRUSTEE, EXECUTOR, OR ADMINISTRATOR INFORMATION
(a). Name of the trustee, executor, or administrator:
(b). Telephone number where questions can be directed:
(c). Street address or rural route number, city, state, and ZIP code of trustee, executor or administrator:
(d). Mailing address if different from street address:
4.
(
)
TRUSTS ONLY:
(a) Grantor’s name: _________________________________________________________________________________________________________________________
(b) Is your trust revocable at the discretion of the grantor in such a manner that revocation results in the title to the trusted land reverting either directly or indirectly to the grantor?
(c) Is your trust revoked or terminated by its terms upon the expiration of a specified period of time in such a manner that revocation or termination results in the title to the trusted
land reverting either directly or indirectly to the grantor?
(d) If your answer to 4(b) or 4(c) is “YES,” was your trust created on or after January 1, 1981?
5.
TRUSTS ONLY:
□
(a) Does your trust own 100 percent of another entity or is your trust affiliated with a nominee partnership?
□
YES
(b) If “YES,” list the name(s) of the entity(s) or nominee partnership(s) and check the appropriate box. For additional space, use attachments.
□
____________________________________________________________________________________________
(c) Does your trust include a class of beneficiaries?
YES
□
□
□
YES
YES
YES
□
□
□
NO
NO
NO
NO
WHOLLY OWNED ENTITY
□
NOMINEE PARTNERSHIP
NO
Name of state(s) or country(ies) where trust or estate is established or registered:
Names of natural persons/entities attributed with the land held in your trust or estate. For additional space, use attachments.
Executor
Grantor
(a)
Name
Trustee
(b)
Relationship to the
Trust or Estate
Beneficiary
6.
7.
□
□
(c)
EIN
(d)
Status of Natural
Person or Entity
(check one)
Prior Law
(e)
Percentage of
Trust or Estate
Attributed to This
Natural Person or
Discretionary
Entity
TOTAL:
1
100%
FORM 7-21TRUST (2012)
8.
9.
TRUST OR ESTATE NAME:
List all entities that are wholly owned by your trust or estate and that hold 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.
(b)
State(s) or Country(ies) Where
Entity is Established
(a)
Subsidiary
Name:
EIN:
Name:
EIN:
10.
(c)
Legal Description of Land Parcel(s) or
Assessor's Parcel Number(s)
(d)
Number of
Acres
LAND YOUR TRUST OR ESTATE DIRECTLY OWNS
List all irrigable and/or irrigation land parcels westwide that are 100-percent owned by your trust or estate. Include land directly owned by any entity in which your trust or estate owns 100-percent interest.
Include land your trust or estate leases 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.
Other
Lessee/
Sublessee
(c) Operated by:
(check one)
Trustee
(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.)
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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Telephone:
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11.
(e)
Starting Date
(m/d/yr)
TOTAL NUMBER OF ACRES YOUR TRUST OR ESTATE DIRECTLY OWNS
2
(g)
Number of
Acres
FORM 7-21TRUST (2012)
12.
13.
TRUST OR ESTATE NAME:
LAND YOUR TRUST OR ESTATE DIRECTLY LEASES FROM ANOTHER PARTY
List all irrigable and/or irrigation land parcels westwide that your trust or estate leases from another party. Include land directly leased by any entity in which your trust or estate owns
100-percent interest. Do not include land the trust or estate leases 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 your trust or estate 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 trust or estate 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
(c) Operated by:
(check one)
Trustee
(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
above instructions for other needed names.)
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 TRUST OR ESTATE DIRECTLY LEASES
14.
LAND YOUR TRUST OR ESTATE INDIRECTLY OWNS OR LEASES THROUGH OTHER ENTITIES
15.
List all entities that hold irrigable and/or irrigation land in which your trust or estate owns a part (less than 100-percent) interest, and all other trusts or estates in which your trust or estate
owns up to and including 100-percent interest. Do not include land directly held by any entity in which your trust or estate owns 100-percent interest. Instead, include that land in item 10 or
item 13 as appropriate. Include land indirectly held by any entity in which your trust or estate owns 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 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
16.
17.
(b)
Name of Entity
(c)
Entity EIN
(d)
Percentage of
Interest Your
Trust or Estate
Owns in Each
Entity
(e)
Number of
Acres
Owned by
the Entity
in Each
Entity
(f)
(g)
Owned Acreage
Number of
Attributable to
Acres Leased
Your Trust's or
by the Entity
Estate's Interest
in Each
in the Entity
District
(d X e)
(h)
Double-Counting
Adjustments
(1)
Owned
Acres
in (g)
TOTAL NUMBER OF ACRES YOUR TRUST OR ESTATE INDIRECTLY OWNS
TOTAL NUMBER OF ACRES YOUR TRUST OR ESTATE INDIRECTLY LEASES
3
(i)
Leased
Acreage
Attributable to
(2)
Your Trust's or
Adjusted Acres Estate's Interest
[g minus h(1)]
in the Entity
FORM 7-21TRUST (2012)
18. TRUST OR ESTATE NAME:
LANDHOLDINGS SUMMARY
Circle the district at which the origianl form is filed if your trust or estate is 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: Complete Form 7-21XS for your trust or estate if land held in your trust or estate is attributed to any parties who exceed their ownership entitlements and such parties wish to or must have the trustee,
executor, or administrator designate trust or estate land as excess land. Attributed parties designating trust or estate land as excess land must do so on their own Form 7-21XS. If some of this land was
designated as excess by the seller and your trust or estate purchased it without sales price approval by Reclamation, you must designate that land as excess on Form 7-21XS. You must complete a Form 721XS for your trust or estate if your trust or estate holds any land designated as excess for any reason (for example, your trust or estate designated involuntarily acquired land as excess).
** NOTE: Complete Form 7-21FC for your trust or estate if land held in your trust or estate is attributed to any parties who exceed their nonfull-cost entitlements and such parties wish to or must have the trustee,
executor, or administrator select trust or estate land to receive water at full-cost rates. Attributed parties selecting trust or estate land to receive water at full-cost rates must do so on their own
Form 7-21FC.
SIGNATURE(S)
27.
All trustees, executors, or administrators must sign this form unless the trust or a power of attorney authorizes one natural person to sign for the trust or estate.
Attention: This declaration 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 Trustee, Executor, or Administrator
Date
Other Required Signature
Date
Other Required Signature
Date
Other Required Signature
Date
Other Required Signature
Date
Other Required Signature
Date
Other Required Signature
Date
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 declaration 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)
trust or estate 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 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).
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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Telephone:
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Telephone:
1
(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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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
| File Type | application/pdf |
| Author | shartman |
| File Modified | 2011-05-09 |
| File Created | 2011-05-06 |