Rev. 1/2021
Check if address update
Full Legal Name:
Business Name:
Mailing Address:
City, State Zip:
Social Security Number (SSN):
and/or
Employer Identification Number (EIN) or Other TIN:
I certify that the number shown on this form is my taxpayer identifying number.
Signature: Date:
Purpose: This form is for reporting sensitive Personally Identifiable Information as required by law.
Instructions: Return this completed form to your local Irrigation Office. The information will be validated for
accuracy per the Privacy Act of 1974 and you will be required to complete the form again if the information you
provided needs to be updated. For proprietors, grantors of revocable trusts, and estates, provide both your personal
and business name, and both your personal SSN and the EIN or other TIN if one has been obtained.
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 per response. 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 for collection of the Social Security
Number (SSN). 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 for billing, including collections, proper payment application and debt management actions. Routine Use:
Information collected is used by the Bureau of Indian Affairs (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: Mandatory. Not doing so may result in
ineligibility for a waiver, payment plan, and water service. If the agency is required to file documents with the IRS identifying you,
you are required to furnish our office your TIN pursuant to Treasury Regulation §301.6109-1(b). If you do not have a TIN, SSN,
EIN, or other TIN, you are required to obtain one. Failure to provide this information, may result in a $50 fine per document filed
with the IRS per Treasury Regulation §301.6721.
** Contains Controlled Unclassified Information When Completed **
