Form 4130-5 Actual Grazing Use Report

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UNITED STATES
DEPARTMENT OF THE INTERIOR
BUREAU OF LAND MANAGEMENT

Form 4130-5
(November 2009)

FORM APPROVED
OMB NO. 1004–0041
Expires: July 31, 2011

ACTUAL GRAZING USE REPORT

Dear Grazing Operator:
In accordance with the terms and conditions of the permit or lease which authorizes your grazing use, please complete this
form and return to the
Field Office within 15 days
after completing your authorized grazing use (43 CFR 4130.3-2(d)). This information, along with other studies data, is needed to evaluate
the effectiveness of present management. Use a separate line for every day that you either turn livestock in or take livestock out of an
allotment or pasture. Your cooperation in providing accurate information will be appreciated.
Allotment (Name and Number)

FOR BUREAU OF LAND MANAGEMENT (BLM) USE ONLY

ACTUAL GRAZING USE
PASTURE

DATE
mm/dd/yyyy

CALCULATION OF AUM’S GRAZING USE

NUMBER AND KIND OR
CLASS OF LIVESTOCK
TURNED IN

TAKEN OUT

NO. AND
KIND OF
LIVESTOCK

GRAZING PERIOD
BEGIN

END

%
PL
USE

AUM’S

I CertIfy That this is a complete and accurate report of my grazing use.
Signature of Permittee/Lessee

Date

Title 18 U.S.C. Section 1001, makes it a crime for any person knowingly and willfully to make to any department or agency of the United
States any false, fictitious, or fraudulent statements or representations as to any matter within its jurisdiction.
(Continued on page 2)

Remarks (Include other information such as death losses, disease, and unauthorized use by strays.):

NOTICES
The Privacy Act of 1974 and the regulations in 43 CFR 2.48(d) provide that you be furnished with the following information in connection with
information required by this permit.
AUTHORITY: Taylor Grazing Act, 43 U.S.C. 315, 316; Federal Land Policy and Management Act, 43 U.S.C. 1701; and Public Rangelands Improvement
Act of 1978, 43 U.S.C. 1901, and 43 U.S.C. 1181d.
PRINCIPAL PURPOSE: Information will be used to document the actual amount of livestock grazing use on the public lands to calculate your billing, and
to help evaluate the effectiveness of management actions in meeting resource management objectives.
ROUTINE USES: (1) This information is being collected to gather and document the actual amount of livestock grazing use on the public lands. (2) This
information will be used to calculate your billing and to help evaluate the effectiveness of management actions in meeting resource management objectives.
(3) Documentation for public information of the grazing use made on public lands. (4) Information from the record and/or the record will be transferred to
appropriate Federal, State, local or foreign agencies, when relevant to civil, criminal or regulatory investigations or prosecutions.
EFFECT OF NOT PROVIDING INFORMATION: Disclosure of the information is required to obtain a benefit in accordance with Sections 3 and 15 of
the Taylor Grazing Act, Section 11 of the Alaska Grazing Act, Section 12 of the Reindeer Act, and Section 302 of the Federal Land Policy and Management
Act.
The Paperwork Reduction Act of 1995 requires us to inform you that:
BLM collects this information to document the purpose, need, and other information for grazing use on the public lands.
Response to this request is required to obtain a benefit.
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 15 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., Washington, D.C. 20240.

(Form 4130-5, page 2)