FS-2200-25 Ownership Statement by Corporation of Partnership

USDA Forest Service OMB No. 0596-0003

Expiration Date: ##/####

Ownership Statement by Corporation or Partnership

(Reference FSM 2230 and FSH 2209.13)

NOTE: The information requested on this form is voluntary; however, all the data requested is necessary if you wish to be considered as a qualified applicant for a grazing permit. The data is requested under authority of 5 USC 301, 36 CFR 222.3.

(Where applicable, to be used in connection with the Application for Grazing Permit)

I hereby certify that as of the date set forth below, the following represents a complete and correct list of the

stockholders or partners of the

     

(Name of corporation or partnership)

with the title, signing authority, mailing address, shares owned, or ownership interest of each:

Name

Title

Mailing Address

Shares of Corporation Owned

Ownership Interest in the Partnership (%)

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

NOTE: Designate by an “X” to the left of the name the stockholder(s) or partner(s) who is authorized by the organization to sign Forest Service grazing applications and permits.

I further certify that the

     

(name of corporation or partnership) is

authorized to conduct business in the State of

     

(see attached documentation of proof of authority)

Additional pages may be used if necessary and will become appended to and part of this statement.

(Seal, if a Corporation)

Signature of Applicant      

Date      

Title      

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0596-0003. The time required to complete this information collection is estimated to average 10 minutes including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

Previous edition of this form is obsolete FS-2200-25 (05/2009)