Form 5-5522 Modification of Grazing Permit

Form 5-5522		OMB No. 1076-0157
	UNITED STATES	Expires ##/##/####
	DEPARTMENT OF THE INTERIOR
	BUREAU OF INDIAN AFFAIRS	Modification No. ___
	MODIFICATION OF GRAZING PERMIT (5-5515)

Permittee ____________________________		Range Unit ___________________________
Contract No. __________________________		Agency ______________________________
Date of Permit ________________________		Reservation __________________________

BY AUTHORITY OF LAW and under the regulations at 25 Code of Federal Regulations 166, the above cited grazing permit, as previously modified by Modification number(s) ____________ , is hereby modified as shown below:

Purpose of Modification: _________________________________________________________________________

_____________________________________________________________________________________________

Permitted Lands		From		To
	Tribal	________________acres		________________acres
	Individually Held	________________acres		________________acres
	Government-owned	________________acres		________________acres
On-and-Off Lands
	Fee	________________acres		________________acres
	Leased	________________acres		________________acres
	Allottee Use	________________acres		________________acres
Season of Use
	Turn Out	____/____/______		____/____/______
	Take Off	____/____/______		____/____/______
Livestock Kind and Number
	Kind (cattle, horses, sheep, goats …)	____________________		____________________
	Number of Head under Permit	____________________		____________________
	Number of Head under On-and-Off	____________________		____________________
	Number of Head under Allottee Use	____________________		____________________
	Total Number of Head	____________________		____________________
Fees
	Annual Grazing Rental	$ ___________________		$ ___________________
	Administrative Fee	$ ___________________		$ ___________________
	Tribal Fees	$ ___________________		$ ___________________
	Bond	$ ___________________		$ ___________________

THIS MODIFICATION becomes effective ________________________, and does not change any of the terms, conditions, or stipulations of the permit, except as specifically set forth herein.

Modification Administration Fee: $______________
Approved:		Accepted:
______________________________ ___/___/___		______________________________ ___/___/___
Superintendent		Permittee

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