Form 7-21VERIFY Verification of Landholdings

OMB CONTROL NO. 1006-0005

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

FORM 7-21VERIFY
2012

VERIFICATION OF LANDHOLDINGS

District Name:

For Certification and Reporting Requirements of the
Reclamation Reform Act of 1982

(7-11)
BUREAU OF RECLAMATION

DATE RECEIVED:

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.
1(a). This form verifies the information on the following previously submitted standard RRA form [the date the specified form was signed]. Check only one form to verify:

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7-2180, Dated:

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7-2190, Dated:

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7-21PE, Dated:

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7-2180EZ, Dated:

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7-2190EZ, Dated:

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7-21TRUST, Dated:

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7-2181, Dated:

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7-2191, Dated:

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7-2184, Dated:

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7-2194, Dated:

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1(b). Check one (or both) if a Form 7-21FC and/or a Form 7-21XS is (are) also being verified:
7-21FC, Dated:
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7-21XS, Dated:
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_______________________________________________________________________________________(Enter the name of the landholder exactly as it appears on the standard form which this form
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verifies. Religious and charitable organizations must include a employer identification number if the standard form this form is verifying is dated prior to 1996.)
(WE) ATTEST THAT THE INFORMATION I(WE) PREVIOUSLY SUBMITTED CONCERNING THE LANDHOLDINGS OF THE LANDHOLDER NAMED ABOVE, ON THE FORM(S) SPECIFIED ABOVE
AND ANY ASSOCIATED RRA FORMS, REMAINS TRUE, ACCURATE, AND COMPLETE TO THE BEST OF MY(OUR) KNOWLEDGE. ALSO, I(WE) ATTEST THAT I(WE) HAVE CORRECTLY
IDENTIFIED ALL OPERATORS AND LESSEES (OTHER THAN THE LANDHOLDER NAMED ABOVE) OF ALL LAND OWNED AND LEASED BY THE LANDHOLDER NAMED ABOVE. I(WE) AGREE
THAT ANY CHANGE IN THE LANDHOLDINGS INFORMATION DECLARED IN THIS VERIFICATION WILL BE PROVIDED VERBALLY TO THE DISTRICT(S) WITHIN 30 CALENDAR DAYS OF
SUCH CHANGE, AND A NEW FORM(S) WILL BE FILED WITH THE DISTRICT(S) WITHIN 60 CALENDAR DAYS OF SUCH CHANGE.
3(a). Street address or rural route number, city, state, and ZIP code of landholder/trustee/executor/administrator:

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

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

4(b). Contact person:

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ANNUAL LEASE RENEWAL OR ANNUAL LEASE EXTENSION
Complete if applicable. For additional space, use page 2 of this form or your own similar attachments. See this form’s separate instructions for further guidance regarding annual leases.
5(a). Name of other party to the annual lease:
5(c). Length of annual lease renewal or extension (cannot exceed 12 months):

5(b). Effective date of the annual lease renewal or extension:
5(d). District name:
5(e). Legal description of land parcel(s) or assessor’s parcel number:

CHANGE IN OPERATOR Complete if applicable. For additional space, use page 2 of this form or your own similar attachments.
6(a). Name of previous operator:
6(b). Name of new operator:
6(c). District name:
6(d). Legal description of land parcel(s) or assessor’s parcel number:
SIGNATURE(S) Attention: This verification must be signed and dated. Please read the attestation statement in item 2 above before signing.
7.

Signature of Landholder/Trustee/Executor/Administrator/Authorized
Agent

Date

Signator's Title or Office Held (if applicable)
Other Required Signature

Date

Signature of Spouse or Other Required Signature

Date

Other Required Signature

Date

Other Required Signature

Date

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

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FORM 7-21VERIFY (2012)
LANDHOLDER’S NAME:
ANNUAL LEASE RENEWAL OR ANNUAL LEASE EXTENSION
Name of other party to the annual lease:
Effective date of the annual lease renewal or extension:

Length of annual lease renewal or extension (cannot exceed 12 months):

District name:
Legal description of land parcel(s) or assessor’s parcel number:
Name of other party to the annual lease:
Effective date of the annual lease renewal or extension:

Length of annual lease renewal or extension (cannot exceed 12 months):

District name:
Legal description of land parcel(s) or assessor’s parcel number:
Name of other party to the annual lease:
Effective date of the annual lease renewal or extension:

Length of annual lease renewal or extension (cannot exceed 12 months):

District name:
Legal description of land parcel(s) or assessor’s parcel number:

CHANGE IN OPERATOR
Name of previous operator:
Name of new operator:
District name:
Legal description of land parcel(s) or assessor’s parcel number:
Name of previous operator:
Name of new operator:
District name:
Legal description of land parcel(s) or assessor’s parcel number:
Name of previous operator:
Name of new operator:
District name:
Legal description of land parcel(s) or assessor’s parcel number:

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