Form 7-2180 - Certification Of Individual'S Landholdings - 2016 Page 4

Download a blank fillable Form 7-2180 - Certification Of Individual'S Landholdings - 2016 in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form 7-2180 - Certification Of Individual'S Landholdings - 2016 with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

FORM 7-2180 (2016)

LANDHOLDER’S NAME:

18.

LANDHOLDINGS SUMMARY

Circle the district at which the original form is filed if you are a multidistrict landholder.

19.

DISTRICT NAME(S):

TOTAL

20.

Total directly owned acres:

21.

Total indirectly owned acres:

22.

Total owned acres (item 20 plus item 21):

23.

Total directly leased acres:

24.

Total indirectly leased acres:

25.

Total leased acres (item 23 plus item 24) :

26. Total owned and leased acres (item 22 plus item 25):

* NOTE: You need to complete Form 7-21XS if this total exceeds your ownership entitlement. If some of this land was designated as excess by the seller and you purchased it without sales price

approval by Reclamation, you must designate that land as excess on Form 7-21XS, even if you do not exceed your ownership entitlement. You must complete a Form 7-21XS if you own

any land designated as excess for any reason (for example, you designated involuntarily acquired land as excess).

** NOTE: You need to complete Form 7-21FC if this total exceeds your nonfull-cost entitlement AND you directly or indirectly lease land.

27. Acreage limitation status – Please check one of the following boxes and provide the requested information for that box:

□

I, my spouse, or we hold(s) or held land directly in a district after that district conformed to the discretionary provisions. Name of district that conformed:

_______________________________________________________________ (Not applicable to nonresident aliens or spouses who are both nonresident aliens.)

□

I, my spouse, or we submitted an irrevocable election to conform to the discretionary provisions. List one district where that irrevocable election was filed: ____________________

□

I, my spouse, or we only indirectly hold(s) or held land in a district after that district conformed to the discretionary provisions and I, my spouse, or we currently submit or have submitted a

“Certification of Individual’s Landholding” (Form 7-2180) to that district. Name of district: _______________________________________________________________________ (Not

applicable to nonresident aliens or spouses who are both nonresident aliens.)

□

I or my spouse was married to a person who was subject to the discretionary provisions. Name of that person and district: _____________________________________________

□

Other, please describe: ____________________________________________________________________________________________________________________________

28.

SIGNATURE(S)

Your spouse must sign this form if you are married. This requirement applies even if the land is not jointly held. You may use a written spousal signature authorization to permit one

spouse to sign for the couple.

Attention: This certificate must be signed and dated. Read the following paragraphs before signing.

Under the provisions of 18 U.S.C. 1001, it is a crime punishable by 5 years imprisonment or a fine of up to $10,000, or both,

for any person to knowingly and willfully submit or cause to be submitted to any agency of the United States any false or

fraudulent statement(s) as to any matter within the agency’s jurisdiction. False statements by the landowner or lessee will also

result in loss of eligibility. Eligibility can only be regained upon the approval of the Commissioner.

Landholder’s Signature

Date

I (we) attest that the information provided herein is true, accurate, and complete to the best of my (our) knowledge and agree

that any change in the landholdings information contained in this certification will be provided verbally to all districts named

within 30 calendar days of such change, and that new forms will be submitted within 60 calendar days of such change. I

(we) further attest that any leases of land receiving irrigation water to which I am (we are) a party are in writing and have

terms that do not exceed 10 years, except perennial crops leases which cannot exceed 25 years and must have written

approval from the Bureau of Reclamation. I (we) also attest that, in my (our) best judgment, the rent paid on any land leased

by or from me (us) that is receiving irrigation water reflects the reasonable value of the irrigation water to the productivity of

Date

Spouse's Signature

the land. In addition, I (we) attest that all landholdings of both spouses, if married, and any dependents (if applicable),

whether held directly or indirectly, have been identified on this form.

This certification is required by Public Law 97-293. Failure to certify can result in prosecution and/or loss of water deliveries from Federal reclamation projects. Information obtained in this certification is protected by the Privacy Act of 1974,

system of records notice INTERIOR/WBR-31, and will be used to administer the acreage limitation provisions of Federal reclamation law. The Secretary of the Interior or the district may require additional information in order to administer these

laws. The Secretary may also require a copy of your lease(s).

PLEASE RETURN THIS FORM TO THE APPROPRIATE DISTRICT OFFICE(S).