Form 5-5520 – Power of Attorney, Page 2 of 2
Permittee Initial _______
IN WITNESS WHEREOF, the parties hereto have caused this agreement to be executed and have set
opposite their respective names the date of execution.
Date of Signature
State of _______________)
County of ______________)
Be it remembered, that on this __________ day of _________________, 20_____, before the
undersigned, a NOTARY PUBLIC in the County and State aforesaid, personally appeared
__________________________________________________________, to me personally known to be
the identical person who executed the within instrument in writing, and such person duly acknowledges
the execution of the same as his or her free and voluntary act.
IN TESTIMONY WHEREOF, I have hereunto subscribed my name and affixed my seal on day and year
last hereinabove written.
My Commission Expires:
Paperwork Reduction Act Statement: This information is collected to manage agriculture and grazing
leases. The information is supplied by a respondent to obtain or retain a benefit, that is, a lease. 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 understand directions, gather the information and fill out the form. If you
wish to make comments on the form, please send them to the Information Collection Control Officer,
Bureau of Indian Affairs, 1849 C Street NW, Mail Stop 4603 MIB, Washington, DC 20240. Note:
comments, names and addresses of commenters 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 it to the extent allowable by law. 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.