Form 7-21XS Designation of Excess Land

OMB CONTROL NO.: 1006-0005

DESIGNATION OF EXCESS LAND

FORM 7-21XS
2012

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

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

Landholder’s ownership entitlement:

□

160 Acres

)

□ 320 Acres

□ 640 Acres

□ 960 Acres

□ Other: ____________Acres

□Trust or estate

6(a)

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

6(b)

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

7.

List all directly owned land to be designated nonexcess. Refer to the separate instructions for further guidance regarding the use of columns (d) and (e). For additional space, use attachments.
(a)
District Name

8.

(c)
Actual Acres

(d) Class 1
Equivalency Factor

(e) Class 1
Equivalent Acres

List all indirectly owned land to be designated nonexcess. This information must be obtained from the direct landowner’s “Designation of Excess Land” (Form 7-21XS) if such a form has been completed
by the direct landowner. Refer to the separate instructions for further guidance regarding column (c). For additional space, use attachments.

(a)
District Name

9.

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

(d)
(c)
Type of Acres Included
Acres Designated
in Item 8(c):
as Nonexcess
(check one)
by the Direct
Class 1
Landowner
Actual
Equivalent

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

(e)
Percentage
Attributed
to This
Landholder

TOTAL NONEXCESS ACREAGE (use the workspace provided in the instructions for item 9 to calculate this total):
1

(f)
Number of
Nonexcess Acres
Attributed to This
Landholder
(c X e)

FORM 7-21XS (2012)
10. LANDHOLDER NAME:
11. List excess land this landholder directly owns westwide.
(a)
District Name

Refer to the separate instructions that accompany this form for special direction regarding item 11(d). For additional space, use attachments.
(c)
Type of Irrigation
Water Received

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

Project

Nonproject

None

(d)
If “Project” is checked in item (c), explain why
land is eligible (e.g., involuntary acquisition,
recordable contract, etc.)
NOTE: If land is receiving water under the involuntary
acquisition provisions, see the separate instructions
on this form.

(e)
Number of
Actual
Excess Acres

12.
TOTAL NUMBER OF ACTUAL EXCESS ACRES THIS LANDHOLDER DIRECTLY OWNS WESTWIDE
13. List excess land indirectly owned westwide that is attributed to this landholder by this landholder’s interest in an entity, trust, or estate. This information must be obtained from the direct landowner’s
“Designation of Excess Land” (Form 7-21XS). Refer to the separate instructions for further guidance regarding column (c). For additional space, use attachments.
(c)
Actual Acres
Designated as
Excess by the
Direct Landowner

(b)
Direct Landowner
Enity, Trust or Estate Name)

(a)
District Name

14.
15.
16.

(e)
(d)
Number of
Percentage
Attributed to Excess Acres Attributed to
This Landowner
This
(c X d)
Landowner

TOTAL NUMBER EXCESS ACRES THIS LANDHOLDER INDIRECTLY OWNS WESTWIDE
TOTAL EXCESS ACREAGE (this is the sum of item 12 and item 14)
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. It is the direct landowner’s responsibility to notify potential buyers of excess land of the actions needed to make the land eligible to receive Reclamation irrigation water.

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

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

Date

Spouse’s Signature or Other Required Signature

Date

Other Required Signature

Date

Other Required Signature

Date

Other Required Signature

Date

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