Form 7-21FC Selection of Full-Cost Land

OMB CONTROL NO.: 1006-0005

FORM 7-21FC
2012
(7-11)

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

SELECTION OF FULL-COST LAND
For Certification and Reporting Requirements of the
Reclamation Reform Act of 1982

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.

1.
2.

Landholder name:
Spouse name, if married:

3(a). Landholder’s, trustee’s, executor’s, or administrator’s street address or rural route

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

number, city, state, and ZIP code:

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

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)

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4(b). Contact person:

□

□

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5.

Landholder’s nonfull-cost entitlement:

6(a).

Entities only: If the reason for completing this form is due solely to a part owner’s need to select land as full-cost, identify the part owner(s):

6(b).

Trusts/Estates only: Identify the attributed direct/indirect landholder(s) who exceeds their nonfull-cost entitlement, causing the trust/estate to complete this form:

7.

8.

160 Acres

320 Acres

960 Acres

Other: ____________Acres

Trust or Estate

List all directly owned and leased land selected to receive Reclamation irrigation water at nonfull-cost rates. Refer to the separate instructions for further guidance regarding the use of columns (d) and
(e). For additional space, use attachments.
(d) Class 1
(e) Class 1
(c)
(b)
(a)
Equivalency Factor
Equivalent Acres
Actual Acres
Legal Description of Land Parcel(s) or Assessor’s Parcel Number(s)
District Name

List all indirectly owned and leased land selected to receive Reclamation irrigation water at nonfull-cost rates. This information must be obtained from the direct landholder’s “Selection of Full-Cost Land”
(Form 7-21FC) if such a form has been completed by the direct landholder. Refer to the separate instructions for further guidance regarding column (c). For additional space, use attachments.

(a)
District Name

9.
10.

0 Acres

(c)
Acres Selected as
Nonfull-Cost
by the
Direct Landholder

(b)
Direct Landholder
(Entity, Trust, or Estate Name)

(d)
Type of Acres
Included in Item 8(c):
(check one)
Actual

Class 1
Equivalent

(e) Percentage
Attributed to This
Landholder

TOTAL NONFULL-COST ACREAGE TO RECEIVE WATER AT NONFULL-COST RATES (use the workspace provided in the instructions for item 9 to calculate this total):

If the total nonfull-cost acreage in item 9 is greater than this landholder’s nonfull-cost entitlement, please explain why:

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(f)
Number of
Nonfull-Cost
Acres Attributed to
This Landholder
(c X e)

FORM 7-21FC (2012)
11. LANDHOLDER NAME:
12. List directly or indirectly owned and leased land that is not receiving Reclamation irrigation water.
(a)
District Name

13.
14.

(d)
(b)
(c)
Actual Acres Selected by the
Legal Description of Land Parcel(s)
Name of the Direct Landholder for
Direct Landholder as Not
or Assessor’s Parcel Number (s) for
Indirectly Held Land
Receiving Reclamation
Directly Held Land
Irrigation Water

(f)
Not
Irrigated

(g)
Receiving
Nonproject
Water

(h)
Number of
Actual Acres
(d X e)

TOTAL NUMBER OF ACTUAL ACRES THAT ARE NOT RECEIVING RECLAMATION IRRIGATION WATER
(c)
Number of
Actual
Full-Cost Acres

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

TOTAL NUMBER OF ACTUAL ACRES THIS LANDHOLDER DIRECTLY OWNS AND LEASES FOR WHICH THE FULL-COST RATE WILL
List indirectly owned and leased land for which the full-cost rate will be paid. This information must be obtained from the direct landholder’s “Selection of Full-Cost Land” (Form 7-21FC). Refer to the
separate instructions for further guidance regarding column (c). For additional space, use attachments.
(c)
Actual Acres
Selected as
Full-Cost by the
Direct Landholder

(b)
Direct Landholder
(Entity, Trust, or Estate Name)

(a)
District Name

17.
18.
19.

(e)
Percent of Actual Acres
Attributable to This
Landholder

List directly owned and leased land for which the full-cost rate will be paid. For additional space, use attachments.
(a)
District Name

15.
16.

For additional space, use attachments.

(d)
Percentage
Attributed to
This
Landholder

(e)
Number of
Full-Cost Acres
Attributed to
This Landholder
(c X d)

TOTAL NUMBER OF ACRES THIS LANDHOLDER INDIRECTLY OWNS AND LEASES FOR WHICH THE FULL-COST RATE WILL BE
TOTAL FULL-COST ACREAGE (this is the sum of item 15 and item 17)
SIGNATURE(S)

This form must be signed and dated as well as the standard form it accompanies. The spouse of a married, individual landholder must sign this form. 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. All partners, joint tenants, or co-tenants must sign this form. However, a written signature authorization may be
used to permit one natural person to sign for the entity. All trustees, executors, or administrators must sign this form unless the trust or a power of attorney authorizes one individual to sign for the trust or estate.

Signature of Landholder, Authorized Agent,
Trustee, Executor, or Administrator

Date

Spouse’s Signature or Other Required Signature

Date

Other Required Signature

Date

Date

Other Required Signature

Date

Other Required Signature

Agent's Title (if applicable) or Other Required Signature and Date

PLEASE RETURN THIS FORM TO THE APPROPRIATE DISTRICT OFFICE(S).
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