Assignment of Liability Form

OMB# 1076-0180

Expires XX-XXXX

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

Paperwork Reduction Act Statement: We are collecting this information subject to the Paperwork Reduction Act (44 U.S.C. 3501) to identify assignee who will be responsible for complying with lease. Your response is voluntary and we will not share the results publicly. We may not conduct or sponsor and you are not required to respond to a collection of information unless it displays a currently valid OMB Control Number. OMB has reviewed and approved this survey and assigned OMB Control Number 1076-0180, which expires ##/##/####.

Estimated Burden Statement: We estimate the form will take you 5 hours to complete, including time to read instructions, gather information, and complete and submit the form. You may submit comments on any aspect of this information collection to the Information Collection Clearance Officer, Office of Regulatory Affairs & Collaborative Action—Indian Affairs (RACA), U.S. Department of the Interior, 1001 Indian School Road NW, Suite 229, Albuquerque, NM 87104.