Reference ID
(Internal Use Only):   	

Legal Description:

BIA Lease Number:	Compliance Due Date:

	

Assignment Liability Form	

Lessee Contact Information:

Assignee:  		Phone Number:		
Address:   				
City:   		State:   		Zip:   		

Non-Compliance Issue(s):

The following work shall be completed by 	:

See letter for other pertinent information regarding instructions, extensions & regulations.

I/We assume the responsibility of the above corrective actions related to the above described lease.

Name (Printed)	
Signature	
Date