7-21VERIFY Verification of Landholdings

OMB CONTROL NO. 1006-0005

FORM 7-21VERIFY
2016

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

VERIFICATION OF LANDHOLDINGS

District Name:

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

(7-15)

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.
1(a). This form verifies the information on the following previously submitted standard RRA form [the date entered must be the date the specified form was signed]. Check only one form to verify:

□ 7-2180

Dated:

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7-2180EZ Dated:

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7-2181 Dated:

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7-2184 Dated:

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□ 7-21TRUST

□ 7-2190

Dated:

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7-2190EZ Dated:

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7-2191 Dated:

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7-2194 Dated:

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□ 7-21PE

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7-21FC Dated:

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7-21XS Dated:

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1(b). Check one (or both) if a Form 7-21FC and/or a Form 7-21XS is (are) also being verified:

Dated:

Dated:

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/

2.

(Enter the name of the landholder exactly as it appears on the standard form which this form verifies. Religious or charitable
organizations must include an employer identification number if the standard form this form is verifying is dated prior to 1996.)

Street address or rural route number, city, state, and ZIP code of
3(a). landholder/trustee/executor/administrator:

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

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

)

4(b). Contact person:

ANNUAL LEASE RENEWAL OR ANNUAL LEASE EXTENSION
Complete if applicable. For additional space, use page 2 of this form or your own similar attachments. See this form’s separate instructions for further guidance regarding annual leases.
5(a). Name of other party to the annual lease:
5(b). Effective date of the annual lease renewal or extension:

5(c). Length of annual lease renewal or extension (cannot exceed 12 months):

5(d). District name:

5(e). Legal description of land parcel(s) or assessor's parcel number:

CHANGE IN OPERATOR
Complete if applicable. For additional space, use page 2 of this form or your own similar attachments.
6(a). Name of previous operator:

6(b). Name of new operator:

6(c). District name:

6(d). Legal description of land parcel(s) or assessor's parcel number:

SIGNATURE(S)
7.

This verification must be signed and dated. Please read the attestation statements below before signing.

Landholder/Trustee/Executor/Administrator/
Authorized Agent

Date

Other Required Signature

Date

Title or office held by Landholder/Trustee/Exectuor/Administrator/
Authorized Agent (if applicable)

Other Required Signature

I(we) attest that the information I(we) previously submitted concerning the landholdings of the
landholder named above, on the form(s) specified above and any associated RRA forms, remains true,
accurate, and complete to the best of my(our) knoldege. Also, I(we) attest that I(we) have correctly
identified all operators and lessees (other than the landholder named above) of all land owned and
leased by the landholder named above. I(we) agree that any change in the landholdings information
declared in this verification will be provided verbally to the district(s) within 30 calendar days of such
change, and a new form(s) will be filed with the district(s) within 60 calendar days of such change.

Date

Signature of Spouse or Other Required Signature

Date

Other Required Signature

Date

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.
This verification is required by Public Law 97-293. Failure to verify can result in prosecution and/or loss of water deliveries from Federal
reclamation projects. Information obtained in this verification 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).

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FORM 7-21VERIFY (2016)
LANDHOLDER’S NAME:
ANNUAL LEASE RENEWAL OR ANNUAL LEASE EXTENSION
Name of other party to the annual lease:
Effective date of the annual lease renewal or extension:

Length of annual lease renewal or extension (cannot exceed 12 months):

District name:
Legal description of land parcel(s) or assessor’s parcel number:
Name of other party to the annual lease:
Effective date of the annual lease renewal or extension:

Length of annual lease renewal or extension (cannot exceed 12 months):

District name:
Legal description of land parcel(s) or assessor’s parcel number:
Name of other party to the annual lease:
Effective date of the annual lease renewal or extension:

Length of annual lease renewal or extension (cannot exceed 12 months):

District name:
Legal description of land parcel(s) or assessor’s parcel number:

CHANGE IN OPERATOR
Name of previous operator:
Name of new operator:
District name:
Legal description of land parcel(s) or assessor’s parcel number:
Name of previous operator:
Name of new operator:
District name:
Legal description of land parcel(s) or assessor’s parcel number:
Name of previous operator:
Name of new operator:
District name:
Legal description of land parcel(s) or assessor’s parcel number:

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