Form 5-5520 - Power Of Attorney (Page 2 of 2) in pdf

IN WITNESS WHEREOF, the parties hereto have caused this agreement to be executed and have set

opposite their respective names the date of execution.

Date of Signature

____________________________

Permittee

____________________________

Permittee

State of _______________)

)ss

County of ______________)

Be it remembered, that on this __________ day of _________________, 20_____, before the

undersigned, a NOTARY PUBLIC in the County and State aforesaid, personally appeared

__________________________________________________________, to me personally known to be

the identical person who executed the within instrument in writing, and such person duly acknowledges

the execution of the same as his or her free and voluntary act.

IN TESTIMONY WHEREOF, I have hereunto subscribed my name and affixed my seal on day and year

last hereinabove written.

(Seal)

_____________________________________________

Notary Public

_____________________________________________

My Commission Expires:

Paperwork Reduction Act Statement: This information is collected to manage agriculture and grazing

leases. The information is supplied by a respondent to obtain or retain a benefit, that is, a lease. 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 understand directions, 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,

Bureau of Indian Affairs, 1849 C Street NW, Mail Stop 4603 MIB, Washington, DC 20240. Note:

comments, names and addresses of commenters are available for public review during regular business

hours. If you wish us to withhold this information, you must state this prominently at the beginning of your

comment. We will honor it to the extent allowable by law. 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.

Form 5-5520 – Power of Attorney, Page 2 of 2

Permittee Initial _______

Form 5-5520 - Power Of Attorney Page 2