Form 5450-17 Export Determination

OMB CLEARANCE
NO. 1004-0058
Expires May 31, 1983

UNITED STATES
DEPARTMENT OF THE INTERIOR
BUREAUOFLANDMANAGEMENT

Location of facility
to be processed.

I
EXPORT DETERMINATION

In compliance with requirements of 43 CFR 5424.1,

Timber
officer.

0

I

0

We

Yes

n

No (I/ “Yes”,

Timber is expected

INSTRUCTIONS
sale applicant forwards information

to authorized

hereby submit the following information:

(1) Have you exported private timber from lands tributary to the above processing facility
a

where Federal

within the last 12 months?

give date o/ last export sale.)

a. Export (dute)
(2) Provide names of affiliates * who have exported private timber from lands tributary to the above processing facility
last 12 months and date of last export sale.
a. Affiliate

Export date

b. Affiliate

Export date

c. Affiliate

Export date

within the

*See 43 CFR 5424. O-5
Name of Firm
Signature of Signing Officer

(See

statementon reverse)

Title

Date

Form 5450-17

(runt. IOZXI>

The Bureau of Land Management collects this information
pursuant to the law (see 43 CFR 5400.0-3(c)).
The

Bureau

of Land Management

determine

whether

Federal

exported

private

timber

uses the information

timber has been substituted
(see

43

CFR

5400.0-5(n)

to
for
and

5424.0-6(c)(2)).
A Bureau
gated

of Land

to report

above-numbered

this

Management
information

contract

timber

purchaser

under provisions

is obliof the

(see 43 CFR 5424.1).

GPO

831-595