Annual Assessment Waiver Application
OMB # 1076-0141
Expires 01/31/2023
Rev. 01/2020
Irrigation Project: Irrigation Season:
Requester’s Name:
Legal description of the assessable acres I own/lease included under this waiver and service location:
Detailed description of deficiencies in BIA infrastructure preventing water delivery (attach additional pages as needed):
Signature: Date:
Purpose: This form is for requesting an Annual Assessment Waiver which if approved, allows the BIA to waive
the annual operation and maintenance (O&M) assessment for 1 year. For your land to be granted an Annual
Assessment Waiver, BIA must determine that our irrigation facilities are not capable of delivering adequate
irrigation water to owned or leased land due to deficiencies in the irrigation infrastructure per 25 CFR §171.700. If
approved, both parties agree that irrigation water will not be delivered in any quantity to the designated farm unit.
Instructions: Return this completed form to your local Irrigation Office. Please attach additional relevant
documentation (including photos). This waiver application must be received by the Bureau of Indian Affairs prior
to the bill due date for the year for which you are requesting the Annual Assessment Waiver. The Annual
Assessment Waiver is only valid for the year in which it is granted. To obtain an Annual Assessment Waiver for a
subsequent year, you must reapply. In order to be eligible for an Assessment Waiver, your Taxpayer Identification
Number (SSN or EIN) must be on file.
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 The authority for requesting this information is contained in 25 U.S.C. Chapter 11, Irrigation of
Allotted Lands; 31 U.S.C. 3711, Collection and Compromise, and 25 CFR Part 171 Irrigation Operations and Maintenance. The
principal purpose for collecting this and other information is for billing, including collections, proper payment application and
debt management actions. The routine use of this information is to obtain minimum information 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 (25 CFR Section 171.700). Disclosure of information may be to: U.S. Department of Justice or in a
proceeding before a court or adjudicative body; Federal, state, local, or foreign law enforcement agency; Members of Congress;
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.
Providing the information is voluntary; however, not doing so will prevent you from participating in an Assessment Waiver,
Incentive Agreement, and Land Classification/Designation.
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Unit Serial:
Unit Serial:
Unit Serial:
BIA Signatures and Approvals
The BIA certifies that
it is not capable of delivering adequate irrigation water to the farm unit identified above, due to
deficiencies in BIA irrigation facilities. BIA also certifies that inadequate water supply due to natural conditions or
climate is not justification for granting this Annual Assessment Waiver. (25 CFR 171§§ 700-720)
Project Manager/Eng
ineer: Recommend Not Recommend
Regional Irrigation Engineer: Concur Non Concur
Signature: Date:
Agency Superintendent:
Approve Disapprove
Signature: Date:
Please indicate reason for denial in Remarks below.
For Irrigation Project Processing Only
1. Posted in NIIMS? Yes No
2. Assigned
Assessment Waiver
3. Dat
e Waiver Approved (Month Day, Y
4. U
nit/Serial Designation(s)
: U
nit: Serial:
5. Max
imo Asset ID(s)
6. R
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Instructions for Assessment Waiver Package
Water User
Questions regarding this form should be directed to your local Irrigation Program staff. The completed form should be
returned to the Irrigation Program staff along with supporting documentation. Please attach additional relevant
documentation (including photos).
Irrigation Project Staff
The following items shall be included in the Assessment Waiver package.
1) A copy of the current O&M bill that clearly identifies the specific tract of land being considered for waiver,
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 deficiencies hindering BIA’s ability to deliver
3) A copy of any documentation (current or prior year’s work order(s)) requests for infrastructure repair/
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
approval by the Agency Superintendent.
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