Form 2920-1 Land Use Application and Permit

Form 2920-1
(March 2011)

FORM APPROVED
OMB NO.1004-0009
Expires: March 31, 2014

UNITED STATES
DEPARTMENT OF THE INTERIOR

FOR BUREAU OF LAND MANAGEMENT (BLM) USE ONLY

BUREAU OF LAND MANAGEMENT

LAND USE APPLICATION AND PERMIT

Application Number

(Sec. 302(b) of P.L. 94 - 579, October 21, 1976, 43 U.S.C. 1732)

1. Name (first, middle initial, and last)

Address (include zip code)

Phone (include area code)

2. Attach map or sketch showing public lands for which you are applying
to

3. Proposed date(s) of use: from
4. Give legal basis for holding interest in lands in
the State of

Resident
Corporation
Local Government
Other

(Check appropriate box at right and explain.)

5. Are the lands now improved, occupied or used?

6. Do you need access to the land?

Yes

Yes

Partnership
County
State Government

No (If "yes," describe improvements and purposes, identify users and occupants.)

No (Describe needed or existing access)

7a. What do you propose to use the lands for?

b. What improvements and/or land development do you propose? (To complete application processing, engineering and construction drawings
may be required)

c. What is the estimated capital cost?

d. What is the source of water for the proposed use?

$ _________________________________

I CERTIFY That the information given by me in this application is true, complete, and correct to the best of my knowledge and belief and is given in good faith.

(Signature of Applicant)

(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)

PERMIT
Permit Number

Permission is hereby granted to
of
to use the following described lands:
TOWNSHIP

Meridian

RANGE

SECTION

SUBDIVISION

State

County

Acres (number)

for the purpose of
and subject to the following conditions:
1. This permit is issued for the period specified below. It is revocable
at the discretion of the BLM, at any time upon notice. This
permit is subject to valid adverse claims heretofore or hereafter
acquired.
2. This permit is subject to all applicable provisions of the regulations
(43 CFR 2920) which are made a part hereof.
3. This permit may not be assigned without prior approval of the
BLM.
4. Permittee must not enclose roads or trails commonly in public use.
5. Authorized representatives of the Department of the Interior, other
Federal agencies, and State and local law officials will at all times
have the right to enter the premises on official business.
6. Permittee must pay the United States for any damage to its property
resulting from the use.
7. Permittee must notify the BLM of address change
immediately.
8. Permittee must observe all Federal, State, and local laws and
regulations applicable to the premises and to erection or
maintenance of signs or advertising displays including the
regulations for the protection of game birds and game animals, and
must keep the premises in a neat, orderly, and sanitary condition.
9. Permittee must pay the BLM, in advance, the lump sum of
for the period of use authorized
$

by this permit or $
, annually, as rental or
such other sum as may be required if a rental adjustment is made.
10. Use or occupancy of land under this permit will commence within
months fromdate hereof and must be exercised at least
days each year.
11. Permittee must take all reasonable precautions to prevent and suppress
forest, brush, and grass fires and prevent pollution of waters on or in
the vicinity of the lands.
12. Permittee must not cut any timber on the lands or remove other
resources from the land without prior written permission from the
BLM. Such permission may be conditioned by a requirement
to pay fair market value for the timber or other resources.
13. Permittee agrees to have the serial number of this permit marked or
painted on each advertising display or other facility erected or
maintained under the authority of such permit.
14. This permit is subject to the provisions of Executive Order No. 11246
of September 24, 1965, as amended, which sets forth the Equal
Opportunity clauses. A copy of this order may be obtained from the
BLM.
15. Permittee acknowledges, by signing below, that he/she knows,
understands and accepts the terms and conditions under which this
permit is issued.

16. Special conditions (attach additional sheets, if necessary)

Permit issued for period
(Permittee)

From

(BLM)

To

(Date)

(Title)

INSTRUCTIONS

1. Submit, in duplicate, to any local office of the Bureau of Land
Management having jurisdiction of the lands.
2. Applications for Land Use Permits will not be accepted unless a
notification of the availability of the land for non-BLM use (Notice of
Realty Action) has been published in the Federal Register and for 3
weeks thereafter in a newspaper of general circulation. This
provision does not apply in those situations where the publication of

(Continued on page 3)

a (Notice of Realty Action) has been waived by the BLM.
3. Costs of processing the application must be paid by the applicant
in advance.

4. The BLM may require additional information to process
an application. Processing will be deferred until the required
information is furnished by the applicant.

(Form 2920-1, Page 2)

NOTICES
The Privacy Act and 43 CFR 2.48(d) require that you be furnished with the following information in
connection with the information required by this form.
AUTHORITY: 43 U.S.C. 1732 and 43 CFR Part 2920 permit collection of the information requested
by this form.
PRINCIPAL PURPOSE: The BLM uses the information in this form to process your application.
ROUTINE USES: In accordance with the System of Records titled, "Land and Minerals Authorization
Tracking System--Interior, LLM-32," disclosure outside the Department of the Interior may be made: (1) To
appropriate Federal agencies when concurrence or supporting information is required prior to granting or
acquiring a right or interest in lands or resources, (2) To Federal, State, or local agencies or a member
of the general public in response to a specific request for pertinent information, (3) To the U.S. Department
of Justice or in a proceeding before a court or adjudicative body when (a) the United States, the
Department of the Interior, a component of the Department, or when represented by the government, an
employee of the Department is a party to litigation or anticipated litigation or has an interest in such
litigation, and (b) the Department of the Interior determines that the disclosure is relevant or necessary to
the litigation and is compatible with the purpose for which the records were compiled, (4) To an appropriate
Federal, State, local, or foreign agency responsible for investigating, prosecuting, enforcing, or implementing
a statute, regulation, rule, or order, where the disclosing agency becomes aware of an indication of a violation
or potential violation of civil or criminal law or regulation, (5) To a member of Congress or a Congressional
staff member from the record of an individual in response to an inquiry made at the request of that individual,
(6) To the Department of the Treasury to effect payment to Federal, State, and local government agencies,
nongovernmental organizations, and individuals, and (7) To individuals involved in responding to a breach
of Federal data. The BLM will only disclose this information in accordance with the Freedom of Information
Act, the Privacy Act, and the provisions at 43 CFR 2.56(c).
7KH3DSHUZRUN5HGXFWLRQ$FWrequires us to inform you that:
The BLM collects this information to process applications for land use authorizations, in accordance with
43 CFR Part 2920.
You do not have to respond to this or any other Federal agency-sponsored information collection unless it
displays a valid OMB control number.
EFFECT OF NOT PROVIDING INFORMATION: Submission of the requested information is necessary to
obtain or retain a benefit. Failure to submit all of the requested information or to complete this form may result
in delay or preclude the BLM's acceptance of your form.
BURDEN HOURS STATEMENT: The estimated public reporting burden for this form is 1 hour per
response for the majority of responses, including the time for reviewing instructions, gathering and maintaining
data, and completing and reviewing the form. For more complex responses, the estimated public reporting
burden is 120 hours per response, including the time for reviewing instructions, gathering and maintaining data,
and completing and reviewing the form. You may submit comments regarding the burden estimate or any other
aspect of this form to: U.S. Department of the Interior, Bureau of Land Management (1004-0009),
Bureau Information Collection Clearance Officer (WO-630), 1849 C Street, N.W., Washington, D.C. 20240.

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(Form 2920-1, page 3)