2540-3 Color-of-title Tax Levy and Payment Record

Print

FORM APPROVED
OMB NO. 1004-0029
Expires: March 31, 2019

UNITED STATES
DEPARTMENT OF THE INTERIOR
BUREAU OF LAND MANAGEMENT

Form 2540-3
(May 2016)

Clear

COLOR - OF - TITLE TAX LEVY AND PAYMENT RECORD

Serial Number

Applicant’s last name
Give legal description of land claimed
TOWNSHIP

RANGE

SECTION

SUBDIVISION

Meridian
TAX YEAR

(Continued on page 2)

County
PAYOR

State
AMOUNT OF TAX
LEVY

PAYMENT

(Form 2540-3, page 1)

TAX YEAR

AMOUNT OF TAX

PAYOR

LEVY

PAYMENT

I CERTIFY that the above listing is the correct tax levy and payment data as shown on the official tax records for the lands described.

(Signature)

(Position Title)

Complete Address

Date

Title 18 U.S.C. Section 1001 and Title 43 U.S.C. Section 1212, make it a crime for any person knowingly and willfully to make to any
department or agency of the United States any false, fictitious, or fraudulent statements or representations as to any matter within its
jurisdiction.
INSTRUCTIONS

(REQUIRED FOR CLASS 2; REQUESTED FOR CLASS 1)

1. Type or print plainly in ink. Attach copy of Color-of-Title
Application (Form 2540-1).
2. Give information requested, in chronological order, for each year

(Continued on page 3)

from January 1, 1901 to date of filing application.
3. This form must be certified to by proper county official or
abstractor, e.g. tax assessor.

(Form 2540-3, page 2)

NOTICES

The Privacy Act of 1974 and the regulation in 43 CFR 2.48 (d) require that you be furnished the following information in connection with
information required by this form.
AUTHORITY: 43 CFR part 2540.
PRINCIPAL PURPOSE: The information is to be used to process your application and to document the administrative action relating to
the application.
ROUTINE USES: In accordance with the System of Records titled, “Land and Minerals Authorization Tracking System—Interior, LLM32,” disclosure outside the Department of the Interior may be made: (1) To appropriate Federal agencies when concurrence or supporting
information is required prior to granting or acquiring a right or interest in lands or resources, (2) To Federal, State, or local agencies
or a member of the general public in response to a specific request for pertinent information, (3) To the U.S. Department of Justice
or in a proceeding before a court or adjudicative body when (a) the United States, the Department of the Interior, a component of the
Department, or when represented by the government, an employee of the Department is a party to litigation or anticipated litigation or has
an interest in such litigation, and (b) the Department of the Interior determines that the disclosure is relevant or necessary to the litigation
and is compatible with the purpose for which the records were compiled, (4) To an appropriate Federal, State, local, or foreign agency
responsible for investigating, prosecuting, enforcing, or implementing a statute, regulation, rule, or order, where the disclosing agency
becomes aware of an indication of a violation or potential violation of civil or criminal law or regulation, (5) To a member of Congress
or a Congressional staff member from the record of an individual in response to an inquiry made at the request of that individual, (6) To
the Department of the Treasury to effect payment to Federal, State, and local government agencies, nongovernmental organizations, and
individuals, and (7) To individuals involved in responding to a breach of Federal data. The BLM will only disclose this information in
accordance with the Freedom of Information Act, the Privacy Act, and the provision in 43 CFR 2.56(c).
The Paperwork Reduction Act of 1995 requires us to inform you that:
BLM collects this information to process your request for Federal lands under the provisions of the Color-of-Title Regulations, found in 43
CFR Section 2540.
Information will be used to illustrate whether the applicant meets requirements of regulations found in 43 CFR Subpart 2540, Subparts
2541-2547.
Response to this request is mandatory, see 43 CFR Subpart 2541.2.
BLM would like you to know that you do not have to respond to this or any other Federal agency-sponsored information collection unless
it displays a currently valid OMB control number.
EFFECT OF NOT PROVIDING INFORMATION: Disclosure of the information is required. If all the information is not provided, the
application may result in delay or preclude the BLM’s acceptance of your form.
BURDEN HOURS STATEMENT: Public reporting burden for this form is estimated at 1 hour per response, including the time for
reviewing instructions, gathering, and maintaining data and completing and reviewing the form. Direct comments regarding the burden
estimate or any other aspect of this form to the U.S. Department of the Interior, Bureau of Land Management (1004-0012), Bureau
Information Collection Clearance Officer (WO-630), 1849 C Street, N.W., Mail Stop 401 LS, Washington, D.C. 20240.

(Form 2540-3, page 3)