OMB 1076-0162 Form 5-5015
Expires 11/30/2022
Page | 3
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In accordance with authority contained in Navajo Nation Resources Development Committee resolution of
February 14, 2017 section III Eligibility requirements to qualify for issuance of a grazing permit on Navajo Partitioned
Lands. Number 6 should new permits be issued for the NPL under 25 CFR 161.401 legally recognized heirs of the
permittee will have first priority.
I __________________________________ Census No. ___________________________
(Name)
The holder of the grazing permit within assigned range unit _______ hereby designate,
____________________________________ Census No. ___________________________
(Name)
To receive this assignment upon my death subject to approval of this designation by the heirship process and the
concurrence of the Bureau of Indian Affairs.
The beneficiary ________________________________________
(Name)
Understands that acceptance of this request subjects him or her to all conditions of the original eligibility requirements
RDCF-20-17 to assume this assignment.
______
Date ________________________ signed _______________________________________________________________
(Print Name) (Signature)
Witnessed: Witnessed:
________________________________________________ _____________________________________________
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 1 hour to complete. 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.
