Homesite Lease Application (Page 4 of 6) in pdf

UNITED STATES DEPARTMENT OF THE INTERIOR BUREAU OF INDIAN

AFFAIRS NAVAJO AGENCY AND NAVAJO NATION

FOR OFFICE USE ONLY

____Field Clearance

____ Land Status

____ EPA Letter

____Consent

____ Archaeology Report

____ Survey Plat

____ Filing Fee

____CRC Form

____ NEPA Fee

____ Certificate of Indian Blood

____ BRC Form

Reviewed by:___________________

_________________________________________________________________________________________________________

HOMESITE LEASE APPLICATION FORM

Date: _____________________

NAME: ________________________________________________________ Census No.__________________ Age: ________

ADDRESS: ________________________________________________________________________________________________

HOME PHONE NO. __________________________________________ WORK NO.: ____________________________________

CELL PHONE NO.____________________________________EMAIL: ________________________________________________

I, (We) hereby apply for one acre or less of Navajo Tribal Land for a homesite lease from the Navajo Nation for the purpose of

developing a private dwelling for the term of sixty-five (65) years within: SECTION _______ TOWNSHIP _______RANGE ________.

CHAPTER: ____________________________________________________________STATE:_____________________________

COUNTY: ____________________________________________________________ AGENCY: ____________________________

GRAZING DISTRICT: __________________________________________________ UNIT: ________________________________

DRAW A MAP SHOWING THE LOCATION AND DIRECTION TO THE PROPOSED HOMESITE.

Latitude:

N Degree:____________________ Minutes:_____________________ Second(s):_____________________

Longitude: N Degree:____________________ Minutes:_____________________ Second(s):_____________________

NAD 83: __________

ACKNOWLEDGEMENT

_________________________________________________

_________________________________

Grazing Official / Land Board Member

Date

FORM – HSLA06

Homesite Lease Application Page 4