7-2184 Certification of Religious or Charitable Organization's

OMB CONTROL NO.: 1006-0005

FORM 7-2184
2016

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

CERTIFICATION OF RELIGIOUS OR CHARITABLE
ORGANIZATION'S LANDHOLDINGS
(Discretionary Provisions)

(7-15)

District Name:

DATE RECEIVED:

BUREAU OF RECLAMATION

Do not use this form after December 31, 2016. 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.

ORGANIZATION INFORMATION
1.

Your organization’s name:

2(a). Your organization’s street address or rural route number, city, state, and zip code:

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

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

3(b). Contact person:

)

4(a). Name of state(s) or country(ies) where your organization is established or registered:

5(a).
5(b).

6.
7.□
8.

4(b). Employer Identification Number (EIN):

Complete name of central organization to which your organization is affiliated (if any):
Subdivisions affiliated with this organization (if any). Refer to the separate instructions for further guidance. NOTE: If you include any subdivisions, those subdivisions must be considered when reference
is made to your organization for the remainder of this form. For additional space, use attachments:

Other names, or entities’ names, through which your organization holds 100-percent interest in irrigable and/or irrigation land. For additional space, use attachments.

□

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Is your organization exempt under Section 501 of the Internal Revenue Code?
YES
NO
If you answer “no” to this question or upon request cannot provide proof of your tax exempt status:
stop, this is not the proper form to complete. Please contact the appropriate Reclamation office immediately for guidance.
(a) Is any part of your organization’s agricultural produce or the proceeds of the sales of such produce used for other than charitable purposes?
(b) Is any irrigable and/or irrigation land held by your organization operated or leased by a party other than your organization, a subdivision of the
organization, or a more central organization of the same affiliation?
(c) Does any part of your organization’s net earnings accrue to the benefit of any private shareholder or individual?

□ YES

□ NO

□ YES

□ NO

□ YES

□ NO

IF YOU ANSWER YES TO 8(a), 8(b), OR 8(c): STOP, THIS IS NOT THE PROPER FORM TO COMPLETE. PLEASE CONTACT THE APPROPRIATE RECLAMATION OFFICE IMMEDIATELY FOR
FURTHER GUIDANCE.

9.

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Acreage limitation status – Please check one of the following boxes and provide the requested information for that box:
Your organization holds or held land directly in a district after that district conformed to the discretionary provisions. Name of district that conformed: ___________________________________________
Your organization submitted an irrevocable election to conform to the discretionary provisions. List one district where that irrevocable election was filed: ________________________________________
Your organization only indirectly holds or held land in a district after that district conformed to the discretionary provisions and your organization currently submits or has submitted a “Certification of
Religious or Charitable Organization’s Landholdings” (Form 7-2184) to that district. Name of district: ________________________________________________________________________________
Other, please describe:

_________________________________________________________________________________________________________________
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FORM 7-2184 (2016)
10. ORGANIZATION’S NAME:
11.

LAND YOUR ORGANIZATION DIRECTLY OWNS

(There is space to list six different parcels [one parcel per line] if
they all are operated by the same natural person or entity in the same
district. For each land parcel that is directly owned by any subdivision
listed in item 5[b], include the name of that subdivision.)

Other

(c)
Operated by:
(check one)
Self

(a)
District Name

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

Lessee/
Sublessee

List all irrigable and/or irrigation land parcels westwide that are 100-percent owned by your organization. Include land your organization leases from a public entity here instead of including it under item 14 .
Identify such land as leased from a public entity and include the name of that public entity after the legal description of the land. For additional space, use Form 7-21CONT-O or your own similar
continuation sheet.
Lease Information
(d)
Identification of the Lessee, Sublessee, or Other Operator

(f)
Ending Date
(m/d/yr)

Name:

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Address:

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Not receiving Reclamation irrigation water

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Land involuntarily acquired

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Name:

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Address:

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Telephone:

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Telephone:

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Not receiving Reclamation irrigation water

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Land involuntarily acquired

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Name:

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Address:

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Not receiving Reclamation irrigation water

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Land involuntarily acquired

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Name:

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Address:

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Not receiving Reclamation irrigation water

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Name:

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Address:

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Not receiving Reclamation irrigation water

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Land involuntarily acquired

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Telephone:

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Telephone:

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Telephone:

12.

(e)
Starting Date
(m/d/yr)

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TOTAL NUMBER OF ACRES YOUR ORGANIZATION DIRECTLY OWNS
2

(g)
Number
of Acres

FORM 7-2184 (2016)
13. ORGANIZATION’S NAME:
LAND YOUR ORGANIZATION DIRECTLY LEASES FROM ANOTHER PARTY

14.

List all irrigable and/or irrigation land parcels westwide that your organization leases from another party. Do not include land your organization leases from a public entity here. Such land is to be included
under item 11. Include the sublessor’s name and the landowner’s name in column (d) if your organization subleases from a sublessor. Include the farm operator's name in column (d) if the land is operated
by a farm operator. You must complete all columns except column (g) if your organization subleases land parcels to others and provide the sublessee’s name and the landowner’s name in column (d).
For additional space, use Form 7-21CONT-L or your own similar continuation sheet.

15.

(For each land parcel that is directly leased by any subdivision
listed in item 5[b], include the name of that subdivision.)

(d)
Landowner’s Name

(c) Operated by:
(check one)

(If the land has been subleased or is
operated by a farm operator, see the
above instructions for other needed names.)

Other

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

Self

(a)
District Name

Lease Information
(e)
Starting Date
(m/d/yr)

(f)
Ending Date
(m/d/yr)

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(g)
Number of
Acres

TOTAL NUMBER OF ACRES YOUR ORGANIZATION DIRECTLY LEASES
LAND YOUR ORGANIZATION INDIRECTLY OWNS OR LEASES THROUGH OTHER ENTITIES

16.

List all entities that hold irrigable and/or irrigation land in which your organization owns a part (less than 100-percent) interest, and all trusts and estates in which your organization owns up to and
including 100-percent interest. You will have to enter an entity’s name on more than one line if it holds irrigable and/or irrigation land in more than one district. Obtain a copy of the entity’s completed
Form 7-2181 or Form 7-2191, or a copy of the trust’s or estate’s completed Form 7-21TRUST to ensure the accuracy of the information you provide. For additional space, use Form 7-21CONT-I or your
own similar continuation sheet.

(a)
District Name

17.
18.

(b)
Name of Entity

(h)
(f)
(i)
(d)
(e)
Double-Counting
Owned Acreage
(g)
Leased Acreage
Percentage of Number of
Attributable to This Number of
Attributable
Adjustments
Interest This Acres Owned
Acres Leased
to This
Organization’s
Organization by the Entity
by the Entity
Organization's
Interest in the
(1)
(2)
in Each
Owns in Each
in Each District Owned Acreage Adjusted Acres
Interest in
Entity
District
Entity
the Entity
(d X e)
in (g)
[g minus h(1)]

(c)
Entity Employer
Identification
Number

TOTAL NUMBER OF ACRES YOUR ORGANIZATION INDIRECTLY OWNS
TOTAL NUMBER OF ACRES YOUR ORGANIZATION INDIRECTLY LEASES
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FORM 7-2184 (2016)
19. ORGANIZATION’S NAME:
LANDHOLDINGS SUMMARY
Circle the district at which the original form is filed if your organization is a multidistrict landholder.

20. DISTRICT NAME(S):

TOTAL

21. Total directly owned acres:
22. Total indirectly owned acres:
*

23. Total owned acres (item 21 plus item 22):
24. Total directly leased acres:
25. Total indirectly leased acres:
26. Total leased acres (item 24 plus item 25):

**

27. Total owned and leased acres (item 23 plus item 26):

* NOTE: You need to complete Form 7-21XS for your organization if this total exceeds your organization’s ownership entitlement. If some of this land was designated as excess by the
seller and your organization purchased it without sales price approval by Reclamation, you must designate that land as excess on Form 7-21XS, even if your organization does
not exceed its ownership entitlement. You must complete a Form 7-21XS if your organization owns any land designated as excess for any reason (for example, your
organization designated involuntarily acquired land as excess).
** NOTE: You need to complete Form 7-21FC for your organization if this total exceeds your organization’s nonfull-cost entitlement AND your organization directly or indirectly leases land.

SIGNATURE

28.
Attention: This certificate 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 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.

Signature of Officer or Authorized Agent of the Certifying Organization

Date

Office Held
I attest that the information provided herein is true, accurate, and complete to the best of my knowledge and agree that any change in the landholdings information contained in this certification will be provided
verbally to all districts named within 30 calendar days of such change, and that new forms will be submitted within 60 calendar days of such change. I further attest that any leases of land receiving irrigation
water to which your organization is a party are in writing and have terms that do not exceed 10 years, except perennial crops leases which cannot exceed 25 years and must have written approval from the
Bureau of Reclamation. I also attest that, in my best judgment, the rent paid on any land leased by or from your organization that is receiving irrigation water reflects the reasonable value of the irrigation water to
the productivity of the land.
This certification is required by Public Law 97-293. Failure to certify can result in prosecution and/or loss of water deliveries from Federal reclamation projects. Information obtained in this certification 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).

PLEASE RETURN THIS FORM TO THE APPROPRIATE DISTRICT OFFICE(S).
4

OMB CONTROL NO.: 1006-0005

CONTINUATION SHEET FOR DIRECTLY OWNED LAND
For Certification and Reporting Requirements of the
Reclamation Reform Act of 1982

FORM 7-21CONT-O
2016
(7-15)
BUREAU OF RECLAMATION

Do not use this form after December 31, 2016. Refer to the instructions of the form for which you are preparing this continuation sheet. You may use this continuation sheet for additional space when listing
directly owned land, or you may use your own similar continuation sheet. Type or print in ink. Date and initial crossouts and corrections. Only landholders subject to prior law provisions should complete column (h).
Use as many of these continuation sheets as necessary. Visit www.usbr.gov/rra for more information.

LANDHOLDER NAME(S):
THIS FORM IS A CONTINUATION OF FORM 7-21__________________ DATED _______________________
LAND THE LANDHOLDER DIRECTLY OWNS

Other

Lessee/
Sublessee

(There is space to list four different parcels
[one parcel per line] if they all are operated by the
same natural person or entity in the same district.)

(c)
Operated by:
(check one)
Self

(a)
District Name

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

Lease Information
(d)
Identification of the Lessee, Sublessee, or Other Operator

(e)
Starting Date
(m/d/yr)

(f)
Ending Date
(m/d/yr)

Name:

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Address:

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Telephone:

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Telephone:

1

(g)
Number
of
Acres

(h)
PRIOR LAW
ONLY
Was Land
Acquired After
12/06/79?

YES

NO

FORM 7-21CONT-O (2016)
LANDHOLDER NAME(S):
THIS FORM IS A CONTINUATION OF FORM 7-21__________________ DATED _______________________
LAND THE LANDHOLDER DIRECTLY OWNS

Other

Lessee/
Sublessee

(There is space to list four different parcels
[one parcel per line] if they all are operated by the
same natural person or entity in the same district.)

(c)
Operated by:
(check one)
Self

(a)
District Name

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

Lease Information
(d)
Identification of the Lessee, Sublessee, or Other Operator

(e)
Starting Date
(m/d/yr)

(f)
Ending Date
(m/d/yr)

Name:

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Address:

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Telephone:

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Name:

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Telephone:

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(g)
Number
of
Acres

(h)
PRIOR LAW
ONLY
Was Land
Acquired After
12/06/79?

YES

NO

OMB CONTROL NO.: 1006-0005

FORM 7-21CONT-L
2016

CONTINUATION SHEET FOR DIRECTLY LEASED LAND
For Certification and Reporting Requirements of the Reclamation Reform Act of 1982

(7-15)
BUREAU OF RECLAMATION

Do not use this form after December 31, 2016. Refer to the instructions of the form for which you are preparing this continuation sheet. You may use this continuation sheet for additional space when listing
directly leased land, or you may use your own similar continuation sheet. Type or print in ink. Date and initial crossouts and corrections. Use as many of these continuation sheets as necessary.
Visit www.usbr.gov/rra for more information.

LANDHOLDER NAME(S):
THIS FORM IS A CONTINUATION OF FORM 7-21__________________ DATED _______________________
LAND THE LANDHOLDER DIRECTLY LEASES FROM ANOTHER PARTY

Other

(c) Operated by:
(check one)
Self

(a)
District Name

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

(d)
Landowner’s Name
[If the land has been subleased or is
operated by a farm operator, see the
instructions to the form for other needed names.]

1

Lease Information
(e)
Starting Date
(m/d/yr)

(f)
Ending Date
(m/d/yr)

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(g)
Number of
Acres

FORM 7-21CONT-L (2016)
LANDHOLDER’S NAME:
THIS FORM IS A CONTINUATION OF FORM 7-21__________________ DATED _______________________
LAND THE LANDHOLDER DIRECTLY LEASES FROM ANOTHER PARTY

Other

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

Self

(a)
District Name

(c) Operated by:
(check one)

(d)
Landowner’s Name
[If the land has been subleased or is
operated by a farm operator, see the
instructions to the form for other needed names.]

2

Lease Information
(e)
Starting Date
(m/d/yr)

(f)
Ending Date
(m/d/yr)

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(g)
Number of
Acres

OMB CONTROL NO.: 1006-0005

CONTINUATION SHEET FOR INDIRECTLY HELD LAND
For Certification and Reporting Requirements of the Reclamation Reform Act of 1982

FORM 7-21CONT-I
2016
(7-15)
BUREAU OF RECLAMATION

Do not use this form after December 31, 2016. Refer to the instructions of the form for which you are preparing this continuation sheet. You may use this continuation sheet for additional space when listing indirectly held
land, or you may use your own similar continuation sheet. Type or print in ink. Date and initial crossouts and corrections. Only landholders subject to prior law provisions should complete column (j). Use as many of these
continuation sheets as necessary. Visit www.usbr.gov/rra for more information.

LANDHOLDER NAME(S):
THIS FORM IS A CONTINUATION OF FORM 7-21__________________ DATED _______________________
LAND THE LANDHOLDER INDIRECTLY HOLDS THROUGH OTHER ENTITIES

(a)
District Name

(b)
Name of Entity

(c)
Entity Employer
Identification Number

(f)
(d)
Owned
(e)
(g)
Percentage
Acreage
Number of
Number of
of Interest
Attributable
Acres
Acres Leased
the
to the
Owned by
by the Entity
Landholder
Landholder’s
the Entity in
in Each
Owns in
Interest in the
Each District
District
Each Entity
Entity
(d X e)

1

(h)
Double-Counting
Adjustments
(1)
Owned
Acres
in (g)

(i)
Leased
Acreage
Attributable to
(2)
the
Adjusted
Landholder’s
Acres
Interest in the
[g minus h(1)]
Entity

(j)
PRIOR LAW
ONLY
Was Owned
Land Acquired
After 12/06/79?

YES

NO

FORM 7-21CONT-I (2016)
LANDHOLDER’S NAME:
THIS FORM IS A CONTINUATION OF FORM 7-21__________________ DATED _______________________
LAND THE LANDHOLDER INDIRECTLY HOLDS THROUGH OTHER ENTITIES

(a)
District Name

(b)
Name of Entity

(c)
Entity Employer
Identification Number

(d)
(e)
Percentage
Number of
of Interest
Acres
the
Owned by
Landholder
the Entity in
Owns in
Each District
Each Entity

2

(f)
Owned
Acreage
Attributable
to the
Landholder’s
Interest in the
Entity
(d X e)

(g)
Number of
Acres
Leased
by the Entity
in Each
District

(h)
Double-Counting
Adjustments
(1)
Owned
Acres
in (g)

(i)
Leased
Acreage
Attributable to
the
(2)
Landholder’s
Adjusted
Interest in the
Acres
Entity
[g minus h(1)]

(j)
PRIOR LAW
ONLY
Was Owned
Land Acquired
After 12/06/79?

YES

NO