Fillable Form No. 5-5022: Revised 3-12-19 OMB 1076-0162 Expires (Bureau of Indian Affairs)

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

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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:
ADDRESS: CITY: STATE: ZIP:
TELEPHONE NUMBER:
CHAPTER AFFILIATION:
* * * * FOR OFFICIAL USE ONLY ! (BIA BNR) * * * * *
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Revised 3-12-19
OMB 1076-0162
Expires 11/30/2022
Page | 2
PERMIT# _______ PRECINCT ___UNIT _____
TOTAL SU#______
IDENTIFY NEW BRAND:
Revised 3-12-19
OMB 1076-0162
Expires 11/30/2022
Page | 3
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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Form No. 5-5022: Revised 3-12-19 OMB 1076-0162 Expires (Bureau of Indian Affairs)

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Completed 26 September 2021

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