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OMB Control Number 1076-0181 <br />Expires 6/30/2023 <br />UNITED STATES DEPARTMENT OF THE INTERIOR <br />BUREAU OF INDIAN AFFAIRS <br />RIGHT-OF-WAY APPLICATION <br />Request for the BIA to grant a right-of-way under the terms and provisions of the Act of <br />February 5, 1948 (25 U.S.C. 323-328) and Departmental Regulations at 25 CFR 169. <br />Parcel(s) Affected by Right-of-Way: <br />Landowner Name(s): ___________________________________________________________ <br />Allotment Number(s): ___________________________________________________________ <br />Legal Description: _____________________________________________________________ <br />____________________________________________________________________________ <br />____________________________________________________________________________ <br />Applicant Information <br />Applicant:____________________________________________________________________ <br />Contact information: Sue Ellen Doudrick, Assistant City Engineer, sdoudrick@southbendin.gov (574) 235-5922. <br />Right-of-Way Information <br />General location of the right-of-way:________________________________________________ <br />____________________________________________________________________________ <br />Duration/term (years):_______________________________ <br />Purposes:____________________________________________________________________ <br />____________________________________________________________________________ <br />____________________________________________________________________________ <br />Length (in feet):____ Width (in feet):_____ Depth (in feet):_____ Size (area):_____________ <br />Owner of permanent improvements in right-of-way:___________________________________ <br />Party responsible for constructing, operating, maintaining, and managing permanent <br />improvements in right-of-way:____________________________________________________ <br />APPLICANT EXPRESSLY AGREES TO review and abide by all conditions stated in the right-of- <br />way grant and comply with all provisions of 25 CFR 169. <br />APPLICANT SIGNATURE:________________________________________________ <br />DATE:________________________________________________________________ <br />ATTEST:______________________________________________________________ <br />See the back of this form for: <br />Required supporting documents that must be submitted with this application; and <br />A list of conditions that will be among those in the right-of-way grant. <br />PLEASE SUBMIT THIS FORM & REQUIRED SUPPORTING DOCUMENTS TO THE LOCAL <br />BIA AGENCY OFFICE. <br />PAPER WORK REDUCTION ACT STATEMENT <br />This information is being collected to provide Bureau of Indian Affairs (BIA) with information necessary to issue a grant <br />of a right-of-way across Indian land. Response is required to obtain benefits under 25 CFR 169. A Federal Agency <br />may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a <br />currently valid OMB control number. Public reporting for this form is estimated to average 1 hour per response, <br />including the time for reviewing instructions, gathering and maintaining data, completing the form. Direct comment <br />regarding the burden estimate or any other aspect of this form to: Information Collection Clearance Officer, Office of <br />Regulatory Affairs & Collaborative Action – Indian Affairs, 1849 C Street, N.W., MS-3071-MIB, Washington, D.C. <br />20240. <br />March 22, 2022