Form 7-21FARMOP Declaration of Farm Operator Information

OMB CONTROL NO.: 1006-0005

FORM 7-21FARMOP
2014

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

DECLARATION OF FARM OPERATOR INFORMATION
(For Certification and Reporting Requirements of the
Reclamation Reform Act of 1982)

(7-13)

District Name:

DATE RECEIVED:

BUREAU OF RECLAMATION

Do not use this form after December 31, 2014. 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.

FARM OPERATOR INFORMATION
1.

Farm operator or part owner name:

2(a).

Farm operator type (check one):

□ Individual
□Corporation

□ Part Owner
□ Partnership

□ Joint Tenancy or Tenancy-in-common
□ Other: ____________________________________________
2(b). If you checked “Other” in item 2(a), how is your entity taxed by the Internal Revenue Service (check one box): □ As a corporation □ As a partnership
3(a). Farm operator’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.
6.
7.

)

Name of state(s) or country(ies) where farm operator is established or registered (if applicable):
Employer Identification Number (EIN):

LAND FOR WHICH THE FARM OPERATOR PROVIDES SERVICES
List all irrigable and/or irrigation land parcels westwide for which you provide services that are held in a trust or held by a legal entity. Include land for which your wholly owned subsidiary(ies) provide(s)
services. For additional space, use page 2 of this form.

(a)
District Name

(b)
Legal Description of Land Parcel(s) or
Assessor's Parcel Number(s)
(There is space to list multiple land parcels if they all
[1] are held by the same landholder, [2] are in the same district,
and [3] receive the same farm operating services).

(d)
Identification of the Legal Entity or Trust for Whom
Services are Provided

(c)
Services Provided for Each Parcel

Name:
Address:

□ Self
□ Self

(f) Who decides when services should be provided?
(g) Who decides what will be done on the land parcels on a daily basis?

Telephone:

□ Landholder
□ Landholder

□ Other (please specify):
□ Other (please specify):

Name:
Address:

□ Self
□ Self

(f) Who decides when services should be provided?
(g) Who decides what will be done on the land parcels on a daily basis?

8.

Telephone:

□ Landholder
□ Landholder

□ Other (please specify):
□ Other (please specify):

TOTAL NUMBER OF ACRES LISTED ON THIS PAGE FOR WHICH YOU PROVIDE SERVICES
1

(e)
Number of
Acres

FORM 7-21FARMOP (2014)
9. FARM OPERATOR’S NAME:
10.

LAND FOR WHICH THE FARM OPERATOR PROVIDES SERVICES

Continue listing, as necessary, all irrigable and/or irrigation land parcels westwide for which you provide services that are held in a trust or held by a legal entity. Include land for which your wholly owned
subsidiary(ies) provide(s) services. For additional space, use attachments.

(a)
District Name

(b)
Legal Description of Land Parcel(s) or
Assessor's Parcel Number(s)
(There is space to list multiple land parcels if they all
[1] are held by the same landholder, [2] are in the same
district, and [3] receive the same farm operating services.)

(c)
Services Provided for Each Parcel

(d)
Identification of the Legal Entity or Trust for Whom
Services are Provided

Name:
Address:

(f) Who decides when services should be provided?
(g) Who decides what will be done on the land parcels on a daily basis?

□ Self
□ Self

Telephone:

□ Landholder
□ Landholder

□ Other (please specify):
□ Other (please specify):

Name:
Address:

(f) Who decides when services should be provided?
(g) Who decides what will be done on the land parcels on a daily basis?

□ Self
□ Self

Telephone:

□ Landholder
□ Landholder

□ Other (please specify):
□ Other (please specify):

Name:
Address:

(f) Who decides when services should be provided?
(g) Who decides what will be done on the land parcels on a daily basis?

□ Self
□ Self

Telephone:

□ Landholder
□ Landholder

□ Other (please specify):
□ Other (please specify):

Name:
Address:

(f) Who decides when services should be provided?
(g) Who decides what will be done on the land parcels on a daily basis?

□ Self
□ Self

Telephone:

□ Landholder
□ Landholder

□ Other (please specify):
□ Other (please specify):

Name:
Address:

(f) Who decides when services should be provided?
(g) Who decides what will be done on the land parcels on a daily basis?

11.

□ Self
□ Self

Telephone:

□ Landholder
□ Landholder

□ Other (please specify):
□ Other (please specify):

TOTAL NUMBER OF ACRES LISTED ON THIS PAGE FOR WHICH YOU PROVIDE SERVICES
2

(e)
Number of Acres

FORM 7-21FARMOP (2014)
12. FARM OPERATOR’S NAME:
13.

SUBSIDIARIES OF THE FARM OPERATOR (PARENT ENTITY)

This section is to be completed only by the parent entity of the wholly owned subsidiary(ies) that provide(s) the farm operating services. List any wholly owned subsidiary(ies) of the
parent entity that provides services to legal entities or trusts. For each wholly owned subsidiary(ies), include all irrigable and/or irrigation land parcels westwide for which the
subsidiary(ies) provide(s) services that are held in a trust or held by a legal entity. For additional space, use attachments.
(a)
Subsidiary

(b)
EIN

(c)
Legal Description of Land Parcel(s) or Assessor's Parcel
Number(s) for Acres Receiving Services

Name:

Name:

Name:

Name:

Name:

Name:

14.

PART OWNERS OF THE FARM OPERATOR
List any part owner(s) of the farm operator that provides services to legal entities or trusts. For additional space, use attachments.
(a)
Part Owner

(b)
EIN

(c)
Percentage of
Interest Owned

FARM OPERATION SUMMARY
15. DISTRICT NAME(S):
16. Total number of acres (that are

TOTAL

held in a trust or by a legal entity)
for which the farm operator
provides services:
* NOTE: This number should equal the sum of item 8 and item 11 on this form.

*

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FORM 7-21FARMOP (2014)
17. FARM OPERATOR’S NAME:
LAND INFORMATION

□

18. Did you or your entity (and/or its subsidiaries) formerly own any of the land parcel(s) listed on this form as excess land?
Skip to item 20 if your response to this item is "NO."

19. If you responded “YES” to item 18, was the parcel(s) sold or transferred at a price approved by Reclamation?
If “YES,” to which land parcel(s) does this apply?

20. Can you or your entity (and/or its subsidiaries) use your farm operating agreement with a landholder as collateral in any loan?
If "YES," to which land parcel(s) does this apply?

21. Can you or your entity (and/or its subsidiaries) sue or be sued in the name of the landholding?
If "YES," to which land parcel(s) does this apply?

22. Are you or your entity (and/or its subsidiaries) authorized to receive any payments from the United States Department of Agriculture on
behalf of the landholder?
If "YES," to which land parcel(s) does this apply?

23.

YES

□

NO

□

YES

□

NO

□

YES

□

NO

□

YES

□

NO

□

YES

□

NO

SIGNATURE(S) Please sign the appropriate line(s) according to whether you are an individual or an entity.

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 knowingly
and willfully to 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 farm operator will also
result in loss of eligibility. Eligibility can only be regained upon the
approval of the Commissioner.
I (we) attest that the information provided herein is true, accurate, and
complete to the best of my (our) knowledge.

FOR A FARM OPERATOR WHO IS AN INDIVIDUAL OR A PART OWNER

Signature of Farm Operator or Part Owner

Date

FOR A FARM OPERATOR THAT IS AN ENTITY (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 the entity.)

Signature of Officer or Authorized Agent

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 farm operating agreement.

Date

Office Held

Other Required Signature

Date

Other Required Signature

Date

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