FS-2200-017 Application for Term Private Land Grazing Permit

USDA Forest Service FS-2200-017 (V. 08/2012)

OMB No. 0596-0003 (Exp. 07/2012)

Application for Term Private Land Grazing Permit

(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.

Section A (To be completed by Applicant)

I,

     

of

     

(Name of Applicant)

(Mailing Address Including Zip Code)

do hereby offer to the Forest Service the exclusive grazing use of the privately owned or controlled lands described below in return for a permit to graze livestock on adjacent National Forest System lands as follows:

LIVESTOCK

PERIOD OF USE

NUMBER

KIND

CLASS

FROM

TO

GRAZING ALLOTMENT

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

It is fully understood and agreed that a grazing permit, if issued and accepted pursuant to this application, may be cancelled or suspended, in whole or in part for: (a) failure to comply with the terms and conditions in the grazing permit, regulations of the Secretary of Agriculture on which the permit is based, or annual operating or other instructions of Authorized Officers issued pursuant to the permit; (b) knowingly and willfully making a false statement or representation in this application; (c) conviction for failure to comply with Federal laws or regulations or State and local laws relating to livestock control and to protection of air, water, soil and vegetation, fish and wildlife, and other environmental values when exercising the grazing use authorized by the permit; or (d) because the National Forest System lands or other lands under Forest Service control described in the permit are no longer available for grazing. It is also fully understood and agreed that a grazing permit, if issued pursuant to this application, may be modified to conform to current situations brought about by changes in law, regulations, executive orders, allotment management plans, land management planning or other management needs. A permit issued pursuant to this application may also be modified because of resource conditions or permittee request. Upon issuance of a grazing permit, the Forest Service shall be authorized to enter the applicant’s privately owned or controlled lands described below at any time during the term of the permit in order to ensure that permitted livestock grazing is being conducted in conformance with applicable federal law and regulation, and the terms and conditions of the grazing permit.

The following statements and representations constitute a part of this application for a term private land grazing permit:

1. I own or lease (circle one) and seek grazing authorization for       head of cattle,       head of horses, and/or      head of sheep branded and earmarked as follows:

SHEEP BRAND

2. I own or control the following land, in the       Allotment(s), more particularly described below, which I offer as the basis for a Term Private Land Grazing Permit.

LANDS OWNED

LANDS LEASED

Legal Subdivision

Section

Township

Range

Acres

Legal Subdivision

Section

Township

Range

Acres

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

Total Acres Owned

     

Total Acres Leased

     

Signature of Applicant      

Title      

Date      

Section B (To be completed by Recommending Officer)
1. I have verified the applicant’s ownership and/or control of these lands. Yes No
2. The estimated grazing capacity of the foregoing privately owned or controlled lands offered by the applicant to the Forest Service is       AUMs.
The number, kind, and class of livestock, period of use, and grazing allotment on which the livestock are recommended to graze are as entered below.
LIVESTOCK			PERIOD OF USE
NUMBER	KIND	CLASS	FROM			TO	GRAZING ALLOTMENT
     	     	     	     			     	     
     	     	     	     			     	     
     	     	     	     			     	     
     	     	     	     			     	     
     	     	     	     			     	     
Signature of Recommending Officer      					Name (Print)      			Title      		Date      

Burden Statement

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 20 minutes per response, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, gender, religion, age, disability, political beliefs, sexual orientation, and marital or family status. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA’s TARGET Center at 202-720-2600 (voice and TDD).

To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, DC 20250-9410 or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.

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