Form BIA-DWP-Irr-104 Incentive Agreement

Incentive Agreement

OMB # 1076-0141

Expires MM/DD/YYYY

BIA-DWP-Irr-104

Rev. 2/2019

Irrigation Project: Irrigation Season:

Requester’s Name:

Legal description of the assessable acres owned/leased included under this waiver with unit / serial numbers:

Number of Irrigation Seasons (1 year to 3 years):

Purpose: This form is for requesting an Incentive Agreement which if approved, allows the BIA to waive the annual operation and maintenance (O&M) assessment for 1 to 3 years. For your land to be granted an Incentive Agreement, a landowner or lessee agrees to improve idle lands and BIA determines that it is in the best interest of BIA’s irrigation facility (see 25 CFR §171.610 - 615). The Incentive Agreement concept was created to encourage landowners, lessees, and potential lessees to make improvements to idle lands within BIA irrigation projects, ultimately increasing the value of the land and economic benefit to the owner(s). These lands typically are not (or cannot be) irrigated, and are still Presently Assessable (PA) or in Temporarily Non-Assessable status (TNA).

Instructions: Return this completed form to your local Irrigation Office. Please attach additional relevant documentation (including photos). This waiver application must be received by BIA at least 90 days prior to the beginning of the irrigation season and must include a detailed plan to improve idle lands (25 CFR 171.610) for which you are requesting the Incentive Agreement. In order to be eligible for an Incentive Agreement, your Taxpayer Identification Number (SSN or EIN) must be on file.

Specific improvements to the lands (Attach additional pages as needed):

Detailed Description of Improvements Including Costs to Idle Lands:

Detailed Time Schedule of Improvements:

Section 2

Detailed Time Schedule for Water Delivery During Improvements:

Justification for Use of Irrigation Water During the Improvement Period:

If approved, I am certifying that I shall make the specific improvements to the lands as described below. I also understand that BIA may terminate this Agreement if it determines that I am not complying with the terms and conditions described in this Agreement.

Requester’s Name:

Signature: Date:

Paperwork Reduction Act Notice of 1995 – This information is being collected as required under the Debt Collection Improvement Act of 1996 (DCIA) from individuals and organizations doing business with the government. Public reporting burden for this form is estimated to average 12 minutes to fill out the form, but the negotiation of an irrigation incentive lease takes an average of six hours in total. Direct comments regarding the burden estimate or any other aspect of this form to the Information Collection Clearance Officer, Bureau of Indian Affairs, 1849 C Street, NW, MS-4141, Washington, DC 20240. Note: Comments, names and addresses of commentators are 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. This information is being collected from individuals and organizations doing business with the government as required under the Debt Collection Improvement Act of 1996 (DCIA). Purpose: The principal purpose for collecting this information is so the Bureau of Indian Affairs (BIA) can evaluate an applicant’s request for and approval of an Incentive Agreement. Information collected may also be used for billing, including collections, proper payment application and debt management actions. Routine Use: Information collected is used by the BIA for servicing the account 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. This information may be disclosed 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. The information may also be used for filing tax documents with the Internal Revenue Service (IRS) as required by law pursuant to the routine uses identified in the National Irrigation Information Management System (NIIMS), Interior, BIA-34. Disclosure: Voluntary; however, not doing so will prevent you from participating in or obtaining an Incentive Agreement.

Description of Improvements to BIA Irrigation Infrastructure (To Be Completed By BIA):

BIA Signatures and Approvals

Project Manager/Engineer: Recommend Not Recommend

Signature: Date

Regional Irrigation Engineer: Concur Non Concur

Signature: Date

Agency Superintendent: Approve Disapprove

Signature: Date

For Irrigation Project Processing Only

Please indicate reason for denial in Remarks below.

1. Posted in NIIMS? Yes ☐ No ☐
   
   
   

2. Assigned Assessment Waiver Number:
   
   
   

3. Date Waiver Approved (Month Day, Year):
   
   
   

4. Water Service Delivery:

Unit/Serial	Year 1	Year 2	Year 3
	Yes No	Yes No	Yes No
	Yes No	Yes No	Yes No
	Yes No	Yes No	Yes No
	Yes No	Yes No	Yes No
	Yes No	Yes No	Yes No

5. Maximo Asset ID(s):
   
   
   

6. Remarks:

Instructions for Incentive Agreement Package

Water User

Questions regarding this form should be directed to your local Irrigation Program staff. The completed form should be returned to Irrigation Program staff along with supporting documentation.

Irrigation Project Staff

The following items shall be included in the Incentive Agreement package.

1. A copy of the current O&M bill that clearly identifies the specific tract of land being considered for the Incentive Agreement, including the legal description and/or the Unit/Serial numbers for that tract.

2. A copy of a map and/or aerial photo that shows the location(s) of land deficiencies hindering BIA’s ability to deliver service.

3. A copy of any documentation (current or prior year’s work order(s)) requests for infrastructure repair/rehabilitation, if applicable.

4. A copy of documentation from site visits, historic information and/or current photos, reports, etc.

5. A NIIMS print screen of any cancellation of prior year O&M assessments due to inability to deliver water.

6. A copy of previous Annual Assessment Waivers for this same tract.

This package must be compiled and sent to the Regional Irrigation Engineer for concurrence prior to final review by the Superintendent.

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