DEPARTMENT OF THE INTERIOR
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: _________________________________________________________________________
_____________________________________________________________________________________________
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
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: $______________
______________________________ ___/___/___
______________________________ ___/___/___
Paperwork Reduction Act Statement: This form is covered by the Paperwork Reduction Act. It is used to establish the respective rights and
responsibilities of the respondent and the Federal government. The information is provided by respondents to obtain or retain a benefit. In compliance
with the Paperwork Reduction Act of 1995, as amended, the collection has been reviewed by the Office of Management and Budget and assigned a
number and an expiration date. The number and expiration date are at the top right corner of the form. An agency may not sponsor or conduct, and a
person is not required to respond to, a request for information collection unless it displays a currently valid OMB Control Number. The public reporting
burden is estimated to average 20 minutes per respondent. This includes the time needed to understand the requirements, gather the information,
complete the form, and submit it to the Department. Comments regarding the burden or other aspects of the form may be directed to the Indian Affairs
Information Collection Clearance Officer, Office of Regulatory Affairs – Indian Affairs, 1849 C Street, NW, MS-4141, Washington, DC 20240.
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