Form 7-2565 Public Entity Information Sheet

7-2565 (07-13)
Bureau of Reclamation

OMB Control No.: 1006-0023
OMB Expiration Date: December 31, 2015

PUBLIC ENTITY INFORMATION SHEET
(To be completed by the officer or authorized agent of only those public entities that hold 40 acres or less westwide.)
[Use of this Sheet is to be initiated by Reclamation only.]

For Reclamation Use Only

District name(s):

Date Requested:

Public entity name:
Answer the following questions for your public entity and return the completed sheet to the appropriate
Bureau of Reclamation Office. Refer to the other side for instructions.
1. Number of acres held (directly or indirectly owned or leased) in this district: ______________________
2. Was any of this land designated as excess by the previous owner and acquired without Reclamation sale price approval?

YES

NO

3. Does your public entity hold land in any other district(s) subject to the acreage limitation provisions?
YES
NO
If “YES,” list the district(s) where land is held and the number of acres held in the district(s). If you are unsure of whether
another district is subject to the acreage limitation provisions of Federal reclamation law, contact your appropriate
Reclamation office. Use attachments if necessary.
District Name

Number of Acres

Note: If your public entity holds more than 40 acres westwide, STOP and contact the appropriate Reclamation office for further instructions.

4. Is your public entity a department of the Federal government or a Federal agency?
5. Is your public entity a public school district?

YES

YES

NO

NO

If the answer to the question in either item 4 or item 5 is “YES,” proceed to item 13. If the answers to both
item 4 and item 5 are “NO,” proceed to item 6.
6. Did this public entity, or a legal entity in which this public entity has a 100-percent interest, become the owner of or begin to
lease from another party irrigable and/or irrigation land 1 after December 31, 2004?
YES
NO
If the answer to the question in item 6 is “NO,” proceed to item 13. If the answer to the question in item 5 is
“YES,” proceed to item 7.
7. For the land that your public entity became the owner of or began to lease from another party after December 31, 2004,
list the district(s) in which that land is located and the number of acres owned or leased in each district. Use attachments if
additional space is needed. Total the acres as directed in items 7(a), 7(b), and 7(c) [including any acres listed on attachments],
and then proceed to the second page of this form. Note: For leased land, use the effective date of the lease agreement when
determining whether the land was leased after December 31, 2004. If no effective date is specified in the lease, use the date
the lease was signed.

District Name

(a)

Number of Owned Acres

Number of Leased Acres

TOTAL NUMBER OF OWNED ACRES

(b)

TOTAL NUMBER OF LEASED ACRES

(c)

TOTAL NUMBER OF ACRES IN ITEMS 7(a) AND 7(b)

1

Irrigable land - Land so classified by Reclamation under a specific project plan for which irrigation water is, can be, or is planned to be provided,
and for which facilities necessary for sustained irrigation are provided or are planned to be provided.

Irrigation land - Any land receiving water from a Reclamation project facility for irrigation purposes in a given water year, except for land that has
been specifically exempted by statute or administrative action from the acreage limitation provisions of Federal reclamation law.
Public Entity Copy

Page 1 of 2

7-2565 (07-13)
Bureau of Reclamation

OMB Control No.: 1006-0023
OMB Expiration Date: December 31, 2015

YES

8. Is any or all of the land listed in item 7 currently used for purposes other than those listed below?

NO

► Corrections facilities

► Cemeteries

► Hospitals or similar facilities

► Golf courses

► Facilities for agricultural research, instruction, or education

► Water treatment, waste water facilities, or landfills

► Wildlife mitigation refuges or habitats

► Parks or recreation areas/facilities

► Airports

► Residential assistance facilities

If the answer to item 8 is “NO,” proceed to item 13. If the answer to item 8 is “YES,” proceed to item 9.
9. For land for which the answer to item 8 is “YES,” provide the name of the district(s) in which the land is located, a legal
description of the land or assessor’s parcel number, the number of acres, and a description of the purpose(s) for which the land
is used. Use attachments if additional space is needed. Total the acres as directed (including any acres listed on attachments)
and proceed to item 10.
District Name

Legal Description of Land or
Assessor’s Parcel Number

Number
of Acres

Land Use

TOTAL NUMBER OF ACRES

10. For any of the land listed in the table in item 9, does the public entity receive:
a. Money (or its equivalent) for any of the crop(s) produced?
b. Money (or its equivalent) for lease payments?
c. Any of the crop(s) produced, and all or some of the crop(s) is (are) then sold for money (or its equivalent)?

YES
YES
YES

NO
NO
NO

If any of the answers in item 10 are “YES,” proceed to item 11. If all of the answers in item 10 are “NO,”
proceed to item 13.
11. Did this public entity receive Reclamation irrigation water on or before October 1, 1981?

YES

NO

If the answer to item 11 is “YES,” proceed to item 12. If the answer to item 11 is “NO,” proceed to item 13.
12. In what district(s) was the Reclamation irrigation water received on or before October 1, 1981?

13. Please attest to the following:
I (we) attest that the information provided herein is true, accurate, and complete to the best of my (our) knowledge. Based on the
information provided on this sheet, Reclamation may request additional information.
Print name:

Telephone number:

Signature:

Date:

Office held:

Name of public entity:

This report is required by Public Law 97-293. Failure to complete this form can result in the determination that your public entity is ineligible
to receive Reclamation irrigation water. Information obtained in this form 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.

Public Entity Copy

Page 2 of 2

Paperwork Reduction Act
This information is being collected to establish landholder compliance with Federal reclamation law. Response to this request is
mandatory in accordance with Public Law 97-293 and 43 CFR 426.18. Public reporting burden for this form is estimated to average
15 minutes per response. An agency may not conduct or sponsor, and a person is not required to respond to, a collection
of information unless it displays a currently valid Office of Management and Budget (OMB) control number. Direct comments regarding
the burden estimated or any other aspect of these forms to Manager, Land Resources Office, Code 84-53000, U.S. Bureau of
Reclamation, PO Box 25007, Denver CO 80225.

INSTRUCTIONS FOR COMPLETION

GENERAL Instructions
• When Reclamation has identified a public entity that may hold less than 40 acres westwide, Reclamation will
determine if the public entity should complete this “Public Entity Information Sheet” (Sheet). Reclamation will
send this Sheet directly to the officer or authorized agent of the public entity.
• If your public entity holds more than 40 acres westwide, contact the Reclamation office that provided this Sheet
for further instructions.
• Press firmly when writing to ensure that all copies are legible.
• Visit www.usbr.gov/rra for more information.
RECLAMATION Instructions
• “For Reclamation Use Only” block: Complete all information.
• For recordkeeping purposes, retain the top half-sheet copy (“Originator Copy”) of page 1 of the Sheet at the time
of issuance.
• When the public entity has completed and returned the Sheet to Reclamation:
o Ensure the Sheet is complete.
o Retain the “Reclamation Copy.”
o Provide the “District Copy” to the appropriate district office (if applicable).
PUBLIC ENTITY OFFICER OR AUTHORIZED AGENT Instructions
• Numbers 1 through 5: Enter the requested information. If the answer to either number 4 or 5 is “YES,” proceed
to number 13.
• Number 6: Answer the question provided if the answers to numbers 4 and 5 are both “NO.” If the answer to
number 6 is “NO,” proceed to item 13.
• Numbers 7 through 8: Enter the requested information if the answer to number 6 is “YES.” Provide the
requested totals for numbers 7(a), 7(b), and 7(c); be sure to include in the totals any information provided on
attachments used for additional space. If the answer to number 8 is “NO,” proceed to number 13.
• Numbers 9 through 10: Enter requested information if your answer to number 8 is “YES.” If the answers to
numbers 10(a), 10(b), AND 10(c) are all “NO,” proceed to number 13.
• Number 11: Answer the question provided if your answer to number 10(a), 10(b), OR 10(c) is “YES.” If the
answer to number 11 is “NO,” proceed to number 13.
• Number 12: Enter the requested information if your answer to number 11 is “YES.”
• Number 13: Complete the attestation section.
• Retain the “Public Entity Copy.”
• Return the “Reclamation Copy” and the “District Copy” to the Reclamation office that issued this Sheet.
Refer questions to the Reclamation office that provided this Sheet.

7-2565 (07-13)
Bureau of Reclamation

OMB Control No.: 1006-0023
OMB Expiration Date: December 31, 2015

PUBLIC ENTITY INFORMATION SHEET
(To be completed by the officer or authorized agent of only those public entities that hold 40 acres or less westwide.)
[Use of this Sheet is to be initiated by Reclamation only.]

For Reclamation Use Only

Date Requested:

District name(s):
Public entity name:
Paperwork Reduction Act

This information is being collected to establish landholder compliance with Federal reclamation law. Response to this request is
mandatory in accordance with Public Law 97-293 and 43 CFR 426.18. Public reporting burden for this form is estimated to average
15 minutes per response. An agency may not conduct or sponsor, and a person is not required to respond to, a collection
of information unless it displays a currently valid Office of Management and Budget (OMB) control number. Direct comments
regarding the burden estimated or any other aspect of these forms to Manager, Land Resources Office, Code 84-53000,
U.S. Bureau of Reclamation, PO Box 25007, Denver CO 80225.
Originator Copy