Fill - Free fillable Form No. 5-5022: Revised 3-12-19 OMB 1076-0162 Expires (Bureau of Indian Affairs) PDF form

Revised 3-12-19

OMB 1076-0162

Expires 11/30/2022

Page | 1

Form No. 5-5022

Date: ____________

THE NAVAJO NATION PARTITION LANDS

GRAZING PERMIT MODIFICATION / TRANSFER AGREEMENT

The potential grantee must meet the following eligibility criteria, RDCF-20-17, to obtain an NPL grazing permit:

1. Have lived continuously within the enumerated area where the permit was used.

2. Be an enrolled member of the Navajo Nation.

3. Not have received any of the following accommodations:

a) Signed an accommodation agreement to remain on Hopi Partitioned Lands;

b) Received a permit to graze livestock on lands outside the Navajo Partitioned Lands.

Please attach a copy of the following:

1. Grazing Permit(s).

2. Tribal / State Brand.

3. Conservation and Range Management Plan.

4. Tally count (2 years) and be in compliance.

5. District Grazing Committee approval resolution with meeting minutes, sign-in sheet, and agenda.

NAME OF GRANTOR:

CENSUS NUMBER:

ADDRESS: CITY: STATE: ZIP

TELEPHONE NUMBER:

Gift______ Sold($)_______

Other:____________

DATE OF BIRTH:

CHAPTER AFFILIATION: ________________________________ GPS Coordinates of Grazing Permit Use:

GRAZING PERMIT# _____________ PRECINCT ________ R.U. ________ TOTAL SHEEP UNITS#__________

WILL THE SAME BRAND BE USED: YES / NO Tally Attached: YES / NO Livestock on Permit: Sheep _______ Cattle _______ Goat _________

RELINQUISHMENT OF USE RIGHTS ON NAVAJO PARTITIONED LANDS

I ________________________ census number _____________ Hereby relinquish all use rights to Grazing Permit

number ______ Range Unit ____. And further assert that all livestock and use rights by myself, dependents or heirs

through permitted use have been satisfied and we shall enter no protest.

SIGNED __________________________ DATE __________________

GRANTEE:

1. Do you have a grazing permit? YES / NO NOTE: IF yes, the request for permit transfer will not be approved.

If yes, Grazing Permit number: ________ Sheep Units: _______ Range/District Unit: ____

2. Do you have a Conservation and Management Plan? YES / NO

NAME OF GRANTEE:

CENSUS NUMBER:

ADDRESS: CITY: STATE: ZIP:

TELEPHONE NUMBER:

DATE OF BIRTH:

CHAPTER AFFILIATION:

* * * * FOR OFFICIAL USE ONLY ! (BIA BNR) * * * * *

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Revised 3-12-19

OMB 1076-0162

Expires 11/30/2022

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PERMIT# _______ PRECINCT ___UNIT _____

TOTAL SU#______

IDENTIFY NEW BRAND:

Revised 3-12-19

OMB 1076-0162

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Grantee

Identify State or Tribal Brand.

Indicate your brand here, attach copy of your brand card or grazing permit which designates your brand.

State Brand: Yes No MUST BE KEPT CURRENT

Location of Brand on Animal: ______________________

If you have a state brand: State Brand Number: ______________

State Brand Expiration Date: ____/____/____

As a potential Grantee, I understand that the submission of this application does not guarantee that a

grazing permit transfer will be approved. I understand that any false statements or misrepresentation of

information contained in this application shall be grounds for non-acceptance of this application. All

persons and organizations are released from any liability, whatsoever, as a result of providing such

information as required by the Navajo Nation and the Bureau of Indian Affairs in connection with this

application, and; I do hereby agree to abide by all terms and conditions of the Navajo Nation Grazing

Laws (25 CFR 161), should this application be accepted with favorable consideration.

I understand that if I do not qualify for a grazing permit, a letter stating reasons for my disqualification

will be provided.

Signature: ___________________________________ ___________________________

Grantor Date

___________________________________ ___________________________

Grantee Date

Note:

1. Navajo Partitioned Lands Grazing Permits cannot be subdivided.

2. Incomplete applications will not be accepted.

3. If you do not meet the eligibility requirements, a statement as to why you did not qualify.

Revised 3-12-19

OMB 1076-0162

Expires 11/30/2022

Page | 4

******FOR OFFICIAL USE ONLY******

Approved Denied

_________________________________ _____________________________

District Chairperson BIA Branch of Natural Resources

_________________________________

BIA Regional Office

__________________________________________________________________________________________

Paperwork Reduction Act Statement: This information is collected to manage agriculture and grazing permits. The

information is supplied by a respondent to obtain or retain a benefit, that is, a permit. It is estimated that responding to the

request will take an average of 20 minutes to complete. This includes the amount of time it takes to gather the information

and fill out the form. If you wish to make comments on the form, please send them to: Information Collection Clearance

Officer, Office of Regulatory Affairs – Indian Affairs, 1849 C Street, NW, Mail Stop 4141, Washington, DC 20240.

Comments, including names and addresses of respondents, will be available for public review at this Indian Affairs address

during business hours. Before including your address, phone number, e-mail address, or other personal identifying

information in your comment, you should be aware that your entire comment—including your personal identifying

information—may be made publicly available at any time. 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 expiration

date. The number and expiration date are at the top right corner of the form. Please note that an agency may not conduct or

sponsor, and a person is not required to respond to, a collection of information unless there is a valid OMB clearance number.

Privacy Notice: Authority: 25 CFR 161, Navajo Partitioned Lands Grazing Permits. Purpose: The principal purpose for

collecting the information is to determine eligibility to obtain a Navajo Partitioned Lands Grazing Permit. Routine

Uses: The information will be used by the Bureau of Indian Affairs (BIA) in determining whether an applicant is eligible and

complies with all applicable grazing permit requirements. Information collected may be shared with Navajo Nation members

applying for a permit, the Navajo Tribal Government; U.S. Department of Agriculture, and U.S. Department of Justice.

Disclosure: Voluntary; however, if information is not provided, the BIA cannot make a determination on whether the

applicant is eligible and complies with all applicable grazing and compliance requirements, which may result in non-

acceptance of this application or determined not eligible to receive a permit to graze livestock.

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