Form 5-5519
OMB. No. 1076-0157
Expires: 3/31/2023
I (or we), ______________________________, herein referred to as the Permittee, deposit with the
Superintendent of the ________________________ Agency the sum of $ _______________ to be held
as a cash penal bond to guarantee full performance of the terms of a grazing permit accepted by the
Permittee on Range Unit __________________ of the _________________________ Indian
Reservation for a period beginning __/__/____ and terminating not later than __/__/____.
Bonded Obligation (per 25 CFR 166.601)
One year’s grazing rental
Value of improvements to be constructed
Cost of additional obligations
Total Bond
It is understood that the grazing rental amount will be credited on the last installment of the grazing rental
due under the terms of the permit, provided that the other bonded obligations have been faithfully carried
out by the Permittee.
The Permittee hereby constitutes and appoints the Agency Superintendent as his (or their)
attorney-in-fact and agrees that in case of any default in the performance of any of the conditions or
stipulations of the permit, the attorney-in-fact shall have full power to apply the deposit in the remedy of
any damages, demands, or deficiencies arising by reason of such default as he/she may deem best and
the Permittee hereby for him/herself, heirs, executors, administrators, successors, and assigns, ratifies
and confirms all default remedies the attorney-in-fact may invoke by virtue of these presents.
IN WITNESS WHEREOF, the Permittee hereunto sets his (or their) hand and seal this _____ day of
__________, _____.
(Month) (Year)
Permittee _______________________________
Witness _______________________________
Address _______________________________
Address _______________________________
Permittee _______________________________
Witness _______________________________
Address _______________________________
Address _______________________________
Regional Director
Paperwork Reduction Act Statement: This form is covered by the Paperwork Reduction Act. It is used to establish the respective
rights and responsibilities of the respondent and the Federal government. The information is provided by respondents to obtain or
retain a benefit. 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 an expiration date. The number and expiration date are at the top
right corner of the form. An agency may not sponsor or conduct, and a person is not required to respond to, a request for
information collection unless it displays a currently valid OMB Control Number. The public reporting burden is estimated to average
20 minutes per respondent. This includes the time needed to understand the requirements, gather the information, complete the
form, and submit it to the Department. Comments regarding the burden or other aspects of the form may be directed to the Indian
Affairs Information Collection Clearance Officer, Office of Regulatory Affairs Indian Affairs, 1849 C Street, NW, MS-4141,
Washington, DC 20240.