Form 5-5521
OMB No. 1076-0157
Expires: 3/31/2023
Range Unit:
Permit C. #:
I/We, ______________________________________, Permittee(s) on Range Unit No. ____________ on
the __________________________________ Reservation for the period beginning ___/___/______, and
ending ___/___/______, DO HEREBY CERTIFY that the lands described on the table below are within
or adjacent to the subject range unit, are owned or legally encumbered by me/us for grazing purposes,
and will be used in common with the lands covered by my/our grazing permit on the cited range unit.
Land Type*
Land Description
* Leased Indian Trust, Leased Federal/State, Leased Private, Permittee Owned.
Application is hereby made for an On-and-Off Grazing Permit in accordance with the regulations at 25
CFR 166.308. I/We certify that I/We have signed a Conservation Plan that includes the use of adjacent
trust or non-trust rangelands not covered by the permit to be used in common with permitted lands.
IT IS UNDERSTOOD AND AGREED that the Superintendent will establish the maximum allowable
stocking of all lands to be grazed in common on the range unit.
_______________________________________________(Permittee) ____/____/________
I approve this On-and-Off Grazing Permit and authorize the harvest of _______ AUMS from the above-
described lands through: ____ an increase in the number of animals; ____ a longer season of use.
_______________________________________________(Superintendent) ____/____/________
Permittee Accept:
_______________________________________________(Permittee) ____/____/________
Paperwork Reduction Act Statement: This information is collected to manage agriculture and grazing leases and permits. The information is
supplied by a respondent to obtain or retain a benefit, that is, a lease or 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 the Information Collection Control Officer - Indian Affairs, Office of Regulatory Affairs and Collaborative Action, 1849 C
Street NW, Mail Stop 4141 MIB, Washington, DC 20240. Before including your address, phone number, e-mail address, or other personal identifying
information in your comment, you should be aware that your entire commentincluding your personal identifying informationmay 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.