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pdfOMB CONTROL NO.: 1006-0005
FORM 7-2190EZ
2018
Districts must complete the “District Name” and “Date Received” boxes.
District Name:
“EZ” REPORT OF INDIVIDUAL’S LANDHOLDINGS
(Prior Law Provisions)
DATE RECEIVED:
(7-17)
BUREAU OF RECLAMATION
Do not use this form after December 31, 2018. 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.
You may use this form ONLY IF: (1) All your landholdings subject to acreage limitation provisions are located in only one district, (2) your landholdings subject to acreage limitation provisions total 160 acres or less (320 acres for a married couple,
if each spouse holds an equal interest), (3) you directly hold all your landholdings (that is, the land is not owned or leased through any type of legal entity, such as a corporation, trust, estate, or partnership, or in the names of your children or other
dependents), (4) you are not a dependent, AND (5) you are subject to the prior law provisions. If you do not meet all of these requirements, do not complete this form. Please contact your district office to obtain the proper form.
1.
Landholder name:
□ YES
2(b). If you responded “widowed” to item 2(a), as the surviving spouse were you left with more than
160 acres of land that is eligible to receive Reclamation irrigation water until it is sold?
□
NO
2(a). Marital status:
2(c). Number of acres held prior to death of spouse:
3.
Spouse name:
4(a). Landholder’s street address or rural route number, city, state, and ZIP code:
4(b). Mailing address if different from street address:
5(a). Telephone number where questions can be directed: (
)
Check
the
box
that
indicates
your
citizenship
status.
If
you
are
a
6.
nonresident alien, also enter the country of which you are a citizen.
5(b). Contact person:
Self
Spouse
Country of Citizenship
U.S. Citizen
Resident Alien
Nonresident Alien
7.
LAND YOU OWN
List all irrigable and/or irrigation land parcels that are 100-percent owned by you. Include land you lease from a public entity here. Identify such land as leased from a public entity and
include the name of that public entity after the legal description of the land. You are completing the wrong form if you own land (but not 100-percent interest), or own any land through an
entity. The proper form(s) can be obtained from your district office. For additional space, use Form 7-21CONT-O or your own similar continuation sheet.
(c)
Identification of Lessee, Sublessee, or
Other Operator
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)
(b) Operated by:
(check one)
Self
(a)
Legal Description of Land Parcel(s) or Assessor’s Parcel Number
(d)
Starting Date
(m/d/yr)
(e)
Ending Date
(m/d/yr)
Name:
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Address:
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Telephone:
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Address:
Telephone:
8.
Lease Information
TOTAL NUMBER OF ACRES YOU OWN
1
(f)
Number
of Acres
FORM 7-2190EZ (2018)
9. LANDHOLDER’S NAME:
10.
LAND YOU LEASE FROM ANOTHER PARTY
List all irrigable and/or irrigation land parcels that you lease from another party. Do not include land you lease from a public entity here. Such land is to be included in item 7. Include the sublessor’s name
and the landowner’s name in column (c) if you sublease from a sublessor. Include the farm operator's name in column (c) if the land is operated by a farm operator. You must complete all columns except
column (f) if you sublease land parcels to others and provide the sublessee’s name and the landowner’s name in column (c). You are completing the wrong form if you lease land through an entity.
The proper form(s) can be obtained from your district office. For additional space, use Form 7-21CONT-L or your own similar continuation sheet.
(b) Operated by:
(check one)
Other
Self
(a)
Legal Description of Land Parcel(s) or
Assessor's Parcel Number
(c)
Landowner’s Name
(If the land has been subleased or is
operated by a farm operator, see the
above instructions for other needed names.)
Lease Information
(d)
Starting Date
(m/d/yr)
(e)
Ending Date
(m/d/yr)
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(f)
Number
of Acres
11.
TOTAL NUMBER OF ACRES YOU LEASE
12.
TOTAL OWNED AND LEASED ACRES (item 8 plus item 11)
13. Acreage limitation status – Please check all of the following boxes that apply to you:
□
□
□
I, my spouse, or we do(es) NOT hold and have NEVER held land directly in a district after that district conformed to the discretionary provisions. (Not applicable to nonresident aliens or spouses who are
both nonresident aliens.)
I, my spouse, or we have (has) NEVER submitted an irrevocable election to conform to the discretionary provisions.
I, or my spouse have (has) NEVER been married to a person who was subject to the discretionary provisions.
14.
SIGNATURE(S)
Your spouse must sign this form, if married. This requirement applies even if the land is not jointly held. You may use a written spousal signature authorization to permit one spouse to sign for the couple.
Attention: This report 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.
I (we) attest that the information provided herein is true, accurate, and complete to the
best of my (our) knowledge and agree that any change in the landholdings information
contained in this report will be provided verbally to this district within 30 calendar days
of such change, and that new forms will be submitted within 60 calendar days of such
change. I (we) further attest that any leases of land receiving irrigation water to which I
am (we are) a party are in writing and have terms that do not exceed 10 years, except
perennial crop leases which cannot exceed 25 years and must have written approval
from the Bureau of Reclamation. In addition, (we) attest that all landholdings of both
spouses, if married, are directly held and have been identified on this form.
Landholder's Signature
Date
Spouse's Signature
Date
This report is required by Public Law 97-293. Failure to report can result in prosecution and/or loss of water deliveries from Federal reclamation projects. Information obtained in this report 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.
2
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
2018
(7-17)
BUREAU OF RECLAMATION
Do not use this form after December 31, 2018. 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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(g)
Number
of
Acres
(h)
PRIOR LAW
ONLY
Was Land
Acquired After
12/06/79?
YES
NO
FORM 7-21CONT-O (2018)
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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(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
2018
CONTINUATION SHEET FOR DIRECTLY LEASED LAND
For Certification and Reporting Requirements of the Reclamation Reform Act of 1982
(7-17)
BUREAU OF RECLAMATION
Do not use this form after December 31, 2018. 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 (2018)
LANDHOLDER’S NAME:
THIS FORM IS A CONTINUATION OF FORM 7-21__________________ DATED _______________________
LAND THE LANDHOLDER DIRECTLY LEASES FROM ANOTHER PARTY
Other
Self
(a)
District Name
(b)
Legal Description of Land Parcel(s) or
Assessor's Parcel Number(s)
(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
| File Type | application/pdf |
| Author | shartman |
| File Modified | 2017-06-08 |
| File Created | 2017-06-08 |