FS-2200-016 Application for Term Grazing Permit

USDA Forest Service FS-2200-016 (V. 08/2012)

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

Application for Term 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 apply for a permit to graze livestock on National Forest System lands or other lands under Forest Service control 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; (d) to devote the affected National Forest System lands to another public purpose, including disposal; or (e) 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.

The following statements and representations constitute a part of this application for a term grazing permit.

1. I own 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 the following land which I hereby submit as base property for this grazing permit:

Description:

     

(Section, Township, and Range)

Classified as:

     

     

     

     

(Range)

(Improved Pasture)

(Cultivated)

(Total Acres)

In addition, I own or lease the following lands that are associated with this application:

Classified as:

     

     

     

     

(Range)

(Improved Pasture)

(Cultivated)

(Total Acres)

3. Do you currently hold a lease or permit from the Bureau of Land Management authorizing the grazing of livestock on public lands? Yes No (If yes, provide a copy of the lease or permit.)

Application Continued – Please answer questions 4 through 9

4. Does anyone else possess an ownership interest in the livestock identified in Number 1 above? Yes No (If yes, identify the name and mailing address of all other co-owners of the livestock).

     

5. Do you currently hold, or have interest in, any other Forest Service term permit authorizing grazing on National Forest System lands? Yes No (If yes, provide a copy of the permit.)

     

6. Do you have an application for a term grazing permit currently pending before the Forest Service? Yes No (If yes, provide a copy of the application.)

     

7. Are you submitting this application as an agent or representative of a corporation, partnership, trust, or other legal entity? Yes No (If yes, include copies of a list of shareholders or partners, a list of the officers and directors, or other documents showing full ownership of the organization.)      ______________________________________. 8. Does a managerial agreement regarding the base property and/or permitted livestock exist with a third party? Yes No (If yes, provide a copy of the agreement.)      ___________________________________________

9. I hereby request that the following provision be made part of my grazing permit: (Complete if applicable.)

That I be allowed to graze a total of       head of

     

under an on-and-off provision on the

     

grazing allotment. The land I control together with the adjacent National Forest

System lands or other lands under Forest Service control forms a natural grazing unit. The land I offer consists of       acres I own and       acres I lease or have the right to use more particularly described as follows:

     

A copy of the proof to graze leased (non-owned) land is required.

Signature of Applicant      

Title      

Date      

Section B (To be completed by Recommending Officer)

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 30 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.

Previous versions of this form are obsolete Page 4 of 4 (Print on green paper)