FS-2200-025 Ownership Statement by Corporation of Partnership

USDA Forest Service FS-2200-025 (V. 08/2012)

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

Ownership Statement by Corporation, Partnership or Other Legal Entity

(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, partners or

members for the

     

with the

(Name of corporation, partnership, trust, LLC, or other legal entity as recorded with the State)

signing authority, name, title, mailing address, and share of entity owned OR percentage of entity owned for each:

* Signing Authority	Name	Title	Mailing Address	Share of Entity Owned	Percentage of Entity Owned
     	     	     	     	     	     
     	     	     	     	     	     
     	     	     	     	     	     
     	     	     	     	     	     
     	     	     	     	     	     
     	     	     	     	     	     
     	     	     	     	     	     

* = Designate by an “X” to the left of the name the representative(s) who is authorized by the organization to sign Forest Service grazing applications and permits, AND to send and receive official correspondence.

I further certify that the	     			is authorized to
	(Name of corporation, partnership, trust, LLC, or other legal entity as recorded with the State)
conduct business in the State of		     	(See attached documentation for proof of authority.)

(Affix Seal, If a Corporation)

           

SIGNATURE OF APPLICANT      		DATE
TITLE

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 10 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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