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Form 5-5519

OMB. No. 1076-0157

UNITED STATES

Expires: 01/31/2020

DEPARTMENT OF THE INTERIOR

BUREAU OF INDIAN AFFAIRS

CASH PENAL BOND FOR GRAZING PERMITS

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)

Amount

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 _______________________________

_______________________________

Permittee _______________________________

Witness _______________________________

Address _______________________________

_______________________________

Approved: ______________________________ ___/____/______

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.

Form 5-5519 - Cash Penal Bond For Grazing Permits -Department Of The Interior Bureau Of Indian Affairs

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