Form 4130-1b Grazing Application Supplemental Information

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FORM APPROVED
OMB NO. 1004-0041
Expires: J uly 31, 2011

Form 4130-1b
(November 2009)

FOR BLM USE ONLY
UNITED STATES
DEPARTMENT OF THE INTERIOR
BUREAU OF LAND MANAGEMENT

GRAZING APPLICATION
SUPPLEMENTAL INFORMATION

State: _____________________________________
Office: ____________________________________
Auth. Number: _____________________________
Date Filed:

INSTRUCTIONS: An applicant for a permit/lease that is based on preference should complete this form and submit to the Bureau of Land Management (BLM) along
with completed forms 4130-1a (Grazing Preference Application and Preference Transfer Application) and 4130-1 (Grazing Schedule - Grazing Application). Form
4120-8 (Assignment of Range Improvements) is used to accept assignment of interest and responsibility for maintenance of range improvements used in conjunction with
the subject preference. Form 4120-8 can be obtained only from your local BLM Office. Current permittees or lessees can use Form 4130-1b to update/supersede
previously submitted information. BLM retains original in case record and returns a copy to the permittee/lessee.

APPLICANT NAME:

MAILING ADDRESS:

1. APPLICANT ADDITIONAL QUALIFICATIONS STATEMENT
Complete when submitting application for a new grazing permit/lease.
This section documents whether you meet requirements, besides owning or controlling base property, to qualify for grazing use on public lands.
a. The applicant is a (check only one):
United States citizen, (or, has properly filed a valid declaration of intention to become a citizen or a valid petition for naturalization); or,
i.
ii.

Group or association authorized to conduct business in the State in which the grazing use is sought, all members of which are qualified under “a(i)”; or,

iii.

A corporation authorized to conduct business in the State in which the grazing use is sought.
For group or association, or corporation, indicate the State(s) where it is a registered business entity: ___________________________________________.

b. Answer the following:
Has the applicant or any affiliate had any Federal grazing permit or lease cancelled for violation of the permit or lease within 36 months immediately preceding
the date of this application? (See 43 CFR 4100.0-5 for definition of “affiliate.”)
Yes
No
Has the applicant or any affiliate had any State grazing permit or lease, for lands within allotments for which a Federal grazing permit or lease is sought,
cancelled for violation of the permit or lease within 36 months immediately preceding the date of this application?

Yes

No
Yes

Is the applicant or any affiliate barred from holding a Federal grazing permit or lease by a court of competent jurisdiction?

No

BLM requires that you submit all relevant information we request in order to determine that you meet all qualifications, such as documentation
of incorporation or of group/business association, including information regarding business organization and ownership.
2. OWNERSHIP AND CONTROL OF LIVESTOCK
Complete with application for new permit/lease or to update information regarding an existing permit/lease. If under 43 CFR 4130.7 et seq., a
livestock control agreement is required, failure to file it may result in civil and/or criminal regulatory enforcement actions.
a. The livestock to be grazed under the grazing permit/lease requested by this application (or under my existing permit/lease) are or will be owned by (check all
that apply):
applicant (or permittee/lessee);
other party (except for sons and daughters of applicant or permittee/lessee). (If checked, you must complete part 2(b).)
sons and/or daughters of applicant (or of permittee/lessee); (If checked, please answer the next two questions.)
i. Are the sons/daughters participating in educational or youth programs related to animal husbandry, agribusiness or rangeland management, or are they
actively involved in the family ranching operation and are establishing a livestock herd with the intent of assuming part or all of the family ranching operation?
Yes
No
ii. Will the livestock owned by the sons/daughters comprise 50 percent or less of the total number of livestock authorized to occupy public lands under the
permit/lease requested by this application (or under your existing permit/lease)?

Yes

No

If you answered no to either or both of the immediately preceding questions, you must complete part 2(b).
b. Based on the information you provided in part 2(a), you are required to file with BLM the agreement that gives you (the applicant or permittee/lessee) control
of the livestock that you do not own that will graze under your permit or lease. This agreement must list the kind and number of livestock subject to the
agreement, state who owns them, contain the terms for their care and management, specify the duration of the agreement and be signed by the parties to the
agreement. BLM must approve the agreement prior to any grazing use. You must also file with BLM the brands and other identifying marks of the livestock
subject to the agreement. (See 43 CFR 4130.7 (d), (e) and (f).)
This agreement is (check one):
attached
is not attached but will be submitted to BLM by (date):________________________________________.
(Continued on page 2)

2. OWNERSHIP AND CONTROL OF LIVESTOCK - continued
c. The brands and/or other identifying marks of the livestock that will be grazed under the permit or lease requested by this application (or the existing
permit or lease) are described as follows:
STATE(S) WHERE BRAND(S) IS REGISTERED: ________________________________________________________________________________.
BRAND NAME: ___________________________________________________________________________________________________________.
BRAND IS REGISTERED TO (Name): _________________________________________________________________________________________.
IN THE SPACE BELOW, SKETCH BRAND(S), LOCATION, EARMARKS, AND ANY OTHER IDENTIFYING MARKINGS (e.g. DEWLAP/WATTLE):

3. OWNERSHIP OR CONTROL OF UNFENCED PRIVATE LAND LOCATED WITHIN BLM ALLOTMENTS
Complete with application for new permit/lease or to update information regarding an existing permit/lease. This information helps BLM
account for forage produced on controlled private lands when processing a grazing fee bill.
Does the applicant (or permittee/lessee) own or control (e.g. lease) unfenced private land within BLM allotments that is or will be used in conjunction with
YES (If yes, provide the information below. If necessary, attach additional sheets. NOTE: Use Section 5
the permit or lease requested by this application?
of this form to report other Federal, State or local government grazing permits and leases).
NO
YES

If Yes, may BLM enter this land to estimate its livestock grazing capacity and for other lawful purposes?

LAND IS LEASED AND APPLICANT

HAS NO AUTHORITY TO GRANT ENTRY PERMISSION
NO (NOTE: If BLM cannot verify this land’s livestock grazing capacity, BLM will not take into
account any forage for livestock that occurs on it when calculating the number of livestock BLM authorizes to graze under the permit or lease.)
PROPERTY NAME

NUMBER OF ACRES
OWNED

LEASED

LEGAL DESCRIPTION OF OWNED/CONTROLLED PROPERTY
TNSHP.

RGE.

SEC.

SUBDIVISION.

MERIDIAN

LAND IS IN THIS BLM ALLOTMENT
NAME and NUMBER

4. OTHER BLM GRAZING PERMITS or LEASES
Complete with application for new permit/lease or to update information regarding an existing permit/lease.
Does the applicant (or permittee/lessee) have a BLM grazing permit or lease issued by another BLM district or field office?
YES (If yes, provide the information below. If necessary, attach additional sheets).
DISTRICT OR FIELD OFFICE NAME

(Continued on page 3)

NO

ALLOTMENT NAME AND NUMBER

FORAGE AMOUNT AUTHORIZED (AUM’s)

(Form 4130-1b, page 2)

5. OTHER FEDERAL, STATE AND LOCAL AGENCY GRAZING AUTHORIZATIONS
Complete with application for new permit/lease or to update information regarding an existing permit/lease.
Does the applicant (or permittee/lessee) have a grazing permit, lease or other authorization to graze on land administered by a State or county agency, or another Federal
agency?

YES (If yes, provide the information below. If necessary, attach additional sheets.)
AGENCY NAME

GRAZING AREA or ALLOTMENT LIVESTOCK
NAME
NUMBER / KIND

NO

PERIOD OF USE
BEGIN DATE
END DATE

FORAGE AMOUNT
(AUM’s)

6. DESIGNATION OF AUTHORIZED REPRESENTATIVE
Optional: For applicant (or permittee/lessee) to designate a representative of their choosing to conduct business with BLM. If designating an
authorized representative, submit with application for new permit/lease or to update information regarding an existing permit/lease.

BLM is herein advised that until further written notice, the undersigned applicant or permittee/lessee has authorized the following person
to conduct business and otherwise represent the applicant or permittee/lessee in all matters relating to grazing use on public lands within
the jurisdiction of the __________________________________________ BLM Office.
AUTHORIZED REPRESENTATIVE INFORMATION:

Correspondence Mailing Address:

____________________________________________________________
(Printed Name and Title - as applicable)

Email Address:
Telephone Number(s) [e.g. Day, Night, Mobile]:

____________________________________________________________
(Authorized Representative Signature)

[Upon the designation of a representative and the issuance of a grazing permit or lease, grazing fee billings, official correspondence and other documents
such as grazing decisions or other notices will be sent to the authorized representative acting on behalf of the permittee or lessee. An authorized
representative may not apply to transfer grazing preference on a permittee/lessee’s behalf. An applicant or a permittee/lessee may change or cancel this
designation at any time by submitting the change in writing to the BLM.]

7. APPLICANT (or PERMITTEE/LESSEE) SIGNATURE AND DATE
I will promptly notify BLM in writing of any changed circumstances that affect the accuracy or completeness of the information recorded on this form.

__________________________________________________________________________
(Signature of Applicant or Permittee/Lessee)
________________________________________________________
(Printed Name)

____________________________________________
(Date)

__________________________________________________________________________
(Organizational Title - If applicant or Permittee/Lessee is a Corporation or Group)

Title 18 U.S.C. Section 1001 makes it a crime for any person knowingly and willfully to make any department or agency of the United States any false, fictitious or
fraudulent statements of representations as to any matter within its jurisdiction.
NOTICES
The Privacy Act of 1974 and the regulation in 43 CFR 2.48(d) provide that you be furnished the following information in connection with information required by this application. AUTHORITY:
43 U.S.C. 315, 316, and 1181d; 43 CFR 4100. PRINCIPAL PURPOSE: The information is used to adjudicate applicant’s preference for public land or resources. ROUTINE USES: BLM will
only disclose the information according to the regulations at 43 CFR 2.56. EFFECT OF NOT PROVIDING INFORMATION: Disclosure of this information is necessary to receive a benefit.
Failure to disclose this information may result in BLM’s rejection of your application.
The Paperwork Reduction Act of 1995 requires us to inform you that: BLM collects this information to establish preference for grazing use on public lands. 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. Response to this request is required to receive
a benefit.
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
(1004-0041), Bureau Information Collection Clearance Officer (WO-630), 1849 C Street, N.W., Mail Stop 401 LS, Washington, D.C. 20240.

(Form 4130-1b, page 3)