Form BIA-DWP-Irr-101 Request for Irrigation Services Form

OMB # 1076-0141

Expires MM/DD/YY

BIA-DWP-Irr-101

Rev. 12/2018

Request for Irrigation Services

Irrigation Project: Irrigation Season:

1. Requester’s Name:

Date of Request: Time of Request: a.m. p.m.

2. Service Location.

Unit No.: Serial No.:

Canal/Lateral: Headgate:

3. Time On: a.m. p.m. Date:

Time Off: a.m. p.m. Date:

4. Rate of flow, if available:

5. Number of Acres to Irrigate:

6. Additional information required by the project office responsible for providing your irrigation service:

Purpose: This form is for requesting water delivery, and is subject to having met eligibility requirements.

Instructions: Return this completed form to your local Irrigation Office. Request must be made at least 72 hours and not over 7 days prior to desired time of water delivery. Use one request for each turnout. Water users must be responsible for water until returned to canal. Any additional information required by the project office responsible for providing your irrigation service shall also be provided.

Paperwork Reduction Act Notice of 1995 – This information is being collected to determine the consumer’s water needs and it will be used to determine when and where to deliver water. Response to this request is required to obtain irrigation water. Public reporting burden for this form is estimated to average 30 minutes per response. Direct comments regarding the burden estimate or any other aspect of this form to Attn: Information Collection Clearance Officer – Indian Affairs, 1849 C Street, NW, MS-4141, Washington, DC 20240. Note: comments, names and addresses of commentators is available for public review during regular business hours. If you wish us to withhold this information you must state this prominently at the beginning of your comment. We will honor your request to the extent allowable by law. A federal agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The number and expiration date are displayed in the upper right corner of the form.

Privacy Act Statement – Authority: 25 U.S.C. 11; 31 U.S.C. 3711; and 25 CFR Part 171. Purpose: To use, collect, maintain, and disclose information to determine the consumer’s water needs, to determine when and where to deliver water; to process a consumer’s request for irrigation service at a single point of delivery designated by 25 CFR § 171.200. Routine Use: Information collected are used by the Bureau of Indian Affairs (BIA) to provide irrigation service if you own or lease land within an irrigation project where we assess fees and collect monies to administer, operate, maintain, and rehabilitate project facilities. Information collected may be made available to the U.S. Department of Justice or in a proceeding before a court or adjudicative body; Federal, state, local, or foreign law enforcement agency; Congress; U.S. Department of Treasury to effect payment; Federal agency for collecting a debt; and other Federal agencies to detect and eliminate fraud. Disclosure: Voluntary; however, not doing so will prevent you from receiving irrigation service.