Form 4710-10 APPLICATION FOR ADOPTION OF WILD HORSE(S) OR BURRO(S)

Applicant’s Name

MAP OF LOCATION OF ADOPTED WILD HORSES AND/OR BURROS
Facility Address
State

City
Property Owner(s) Name

Zip Code
Phone Number

Draw a map to the location where animal(s) will be kept (from the
nearest major highway).
N

Draw a layout of corral(s) and shelter(s).
N

Directions to the Facility

INSTRUCTIONS
State. (For the correct address, refer to the pamphlet "Adopting a Wild
1. Carefully read the PROHIBITED ACTS and TERMS OF
Horse or Burro” or take it to an adoption event.)
ADOPTION printed below.
2. Carefully read information provided in the pamphlet " Adopting a Wild
4. So that we may notify you when and where the animal(s) you
Horse or Burro."
requested are available, provide the Bureau of Land Management
office serving your State within 10 days of any change in your address
3. Submit your completed Application for Adoption of Wild Horse(s) or
or telephone number.
Burro(s) to the Bureau of Land Management (BLM) office serving your
PROHIBITED ACTS
(f) Branding a wild horse or burro;
(a) Maliciously or negligently injuring or harassing a wild horse or burro;
(g) Removing or altering a freeze mark on a wild horse or burro;
(b) Treating a wild horse or burro inhumanely;
(h) Violating an order, term, or condition established by the BLM under
(c) Removing or attempting to remove a wild horse or burro from the
this part;
public lands without authorization from the BLM;
(i) Commercially exploiting a wild horse or burro;
(d) Destroying a wild horse or burro without authorization from the BLM,
Any person who commits a prohibited act is subject to a fine of not more
except as an act of mercy;
than $2,000 or imprisonment for not more than one year, or both, for each
(e) Selling or attempting to sell a wild horse or burro or its remains;
violation.

(Continued on next page)

Applicant’s Name
TERMS OF ADOPTION

(f) Adopters must notify the BLM within 30 days of any change in the
adopter's address;

The following terms apply to all wild horses and burros adopted under
this Private Maintenance and Care Agreement:

(g) Adopters must dispose of remains in accordance with applicable
sanitation laws; and

(a) Adopters are financially responsible for providing proper care;
(b) Adopters are responsible, as provided by State law, for any personal
injury, property damage, or death caused by animals in their care, for
pursuing animals that escape or stray, and for costs of recapture;
(c) Adopters must not transfer animals for more than 30 days to another
location or to the care of another individual without the prior
approval of the BLM;
(d) Adopters must make animals available for physical inspection within
7 days of receipt of a written request by the BLM;
(e) Adopters must notify the BLM within 7 days of discovery of an
animal's death, theft or escape;

(h) Title will remain with the Federal Government for at least 1 year
after the Private Maintenance and Care Agreement is executed and
until a Certificate of Title is issued by the BLM.
(i) Adopters are entitled to a replacement if within 6 months of the
adoption date the animal(s) dies or is required to be destroyed due to a
condition that existed at the time of adoption and if the adopter
provides a veterinarian’s statement that certifies that reasonable care
would not have corrected the condition.
Failure to comply with these terms may result in the cancellation of the
agreement, repossession of the animals, and disapproval of requests for
adoption of additional animals. In addition, violation of any term of a
Private Maintenance and Care Agreement is a prohibited act.

I have read and understand the above TERMS OF THE ADOPTION and PROHIBITED ACTIONS.
(Applicant’s Signature)

(Date)

Under penalty of prosecution for violating 18 U.S.C. 1001, which makes it a federal crime to make false statements to any agency of the United
States, I hereby state that I have no intent to sell this wild horse or burro for slaughter or bucking stock, or for processing into commercial
products, within the meaning of the Wild and Free Roaming Horse and Burro Act, 16 U.S.C. 1331 et seq., and regulations 43 CFR 4700.0-5(c). I
have read the above statement, understand the terms of this agreement and agree to comply with them.

(Date)

(Applicant’s Signature)

No. of Burros

Approved for:

No. of Horses Younger than 18 mos.
No. of Horses Older than 18 mos.

No. of Geldings
No. of Trained Animals

Total No. of Animals Approved for Adopter’s Facility

❏ Disapproved (Disapproval will be accompanied by a decision letter to the applicant with appeal rights.)
(BLM Official’s Signature)

(BLM Official’s Printed Name)

(Date)

(Office)

This application expires one year after the date of approval by the BLM Official’s Signature.
NOTICES
The Privacy Act of 1974 and the regulation in 43 CFR 2.48 (d) provide
EFFECT OF NOT PROVIDING INFORMATION: Disclosure of your
that you be furnished the following information in connection with
social security number is mandatory for debt collection purposes.
information required by this agreement.
Disclosure of your driver's license number is required to keep track of the
location of the animal(s). Disclosure of the other information is required
AUTHORITY: 16 U.S.C. 1333 and U.S.C. 7701
to obtain a benefit, that is, one or more wild horses or burros.
The Paperwork Reduction Act of 1995 (44 U.S.C. 3501 et seq.) requires us
PRINCIPAL PURPOSE: The BLM will use this information to process
to inform you that:
your agreement for private maintenance and care of wild horses or burros.
This information is collected to process your application to adopt a wild
BLM will use your driver's license and social security numbers for debt
horse or burro.
collection purposes under the authority of the Debt Collection Act, 31
This information will be used to determine your qualifications to provide
U.S.C. 7700 et seq.
proper care to one or more wild horses or burros.
ROUTINE USES: The primary uses of the information are to: (1)
Identify individuals who have applied to obtain custody of a wild horse(s)
or burro(s); (2) Document disposition of the application, that is, whether
rejected, suspended, granted, or title issued to the animal(s); (3) Record
administrative and adjudicative actions; and (4) Collect debts, when
applicable. Disclosures outside the Department of the Interior will be
made only according to the provisions at 43 CFR 2.56.

Response to this request is required to obtain a benefit, except for your
driver's license number, which is required to keep track of the location and
condition of the animal(s), and for your social security number, which is
mandatory for debt collection purposes.
BLM would like you to know that you do not have to respond to this or
any other Federal agency-sponsored information collection unless it
displays a currently valid OMB control number.

BURDEN HOURS STATEMENT
Public reporting burden for this form is estimated to average 30 minutes per response, including the time for reviewing instructions, gathering and
maintaining data, and completing and reviewing the form. Direct comments regarding the burden estimate or any other aspect of this form to U.S.
Department of the Interior, Bureau of Land Management (1004-0042), Bureau Information Collection Clearance Officer, (WO-630), 1849 C
Street, N.W., Washington, D.C. 20240.
Form 4710-10, page 3)