Form 5-5524 Application for Allocation of Grazing

Form 5-5524		OMB No. 1076-0157
	UNITED STATES	Expires 10/31/2016
	DEPARTMENT OF THE INTERIOR
	BUREAU OF INDIAN AFFAIRS
APPLICATION FOR ALLOCATION OF GRAZING PRIVILEGES

AGENCY _________________________________

TRIBE ____________________________________

I (We) the undersigned enrolled member(s) of the ________________________________ Indian Tribe hereby apply for an allocation of grazing privileges without competitive bidding, as authorized at 25 CFR 166.218, as described in Table 1 below:

Table 1. Requested grazing area and grazing privileges.

Unit/Area	Kind of Stock	Number of Head	Grazing Season (day/month)*			AUMs**
			From	To	Months
			/	/
			/	/
			/	/
			/	/
			/	/
Total Privileges Requested			---	---	---

* For year-long grazing omit dates and indicate 12 under Months.

** AUMS = number of head times number of months. For sheep, divide result by five (5). For horses, multiply result by 1.25.

I (We) certify that the number of livestock over 6 months of age owned by me (us) and to be grazed under my (our) exclusive control and supervision are as follows:

Table 2. Livestock currently owned by applicant.

Kind of Livestock	Number of Head	Brand and Location	Recorded Owner of Brand	Name of Mortgage Holder
Total Number Owned		---	---	---

If this application requests allocated grazing privileges for more livestock than the applicant owns, state briefly the plans made to acquire the additional livestock, including financial arrangements for purchase. ___________________________________________________________________________

____________________________________________________________________________________

If the applicant intends to graze any livestock owned by another person, list the kind, number, and ownership of such livestock:

Table 3. Livestock not owned by applicant to be grazed under allocation.

Kind of Livestock	Number of Head	Brand and Location	Name and Address of Owner	Tribal Member
				Yes ___ No ___
				Yes ___ No ___
				Yes ___ No ___
Total Number of Head		---	---	---

List here any land owned or controlled by you that is available for grazing your livestock. Indicate how many animals this land will support and for how long (Attach additional sheet if needed).

Table 4. Non-allocated lands controlled by applicant.

Land Description	Acres	How Controlled (Owned, Leased, …)	Grazing Capacity
			Number of Head	Months	AUMs
TOTALS		---		---

Do you now allow or intend to allow anyone else to graze or pasture their livestock on any of the lands listed in Table 4 rather than graze your own livestock on these lands?

Yes ____ No ____ If yes, state how many livestock: ______________.

I (We) agree to abide by the regulations at 25 CFR Part 166, and all Tribal grazing regulations and, if a grazing permit is issued, to comply fully with its terms.

__________________________________ (Applicant)	_____________________________________________ (Address)	_________________ (Date)
__________________________________ (Applicant)	_____________________________________________ (Address)	_________________ (Date)
__________________________________ (Applicant)	_____________________________________________ (Address)	_________________ (Date)

Paperwork Reduction Act Statement: This form is covered by the Paperwork Reduction Act.  It is used to establish the respective rights and responsibilities of the respondent and the Federal government. The information is provided by respondents to obtain or retain a benefit.  In compliance with the Paperwork Reduction Act of 1995, as amended, the collection has been reviewed by the Office of Management and Budget and assigned a number and an expiration date.  The number and expiration date are at the top right corner of the form.  An agency may not sponsor or conduct, and a person is not required to respond to, a request for information collection unless it displays a currently valid OMB Control Number.  The public reporting burden is estimated to average 20 minutes per respondent.  This includes the time needed to understand the requirements, gather the information, complete the form, and submit it to the Department.  Comments regarding the burden or other aspects of the form may be directed to the Indian Affairs Information Collection Clearance Officer, Office of Regulatory Affairs – Indian Affairs, 1849 C Street, NW, MS-4141, Washington, DC 20240.

Form 5-5524, Application for Allocation of Grazing Privileges, Page 2 of 2

Permittee Initial ______