Form 4130-1b Grazing Application / Supplemental Informatoin

Form 4130-1b (XXXX 20XX) UNITED STATES DEPARTMENT OF THE INTERIOR BUREAU OF LAND MANAGEMENT GRAZING APPLICATION SUPPLEMENTAL INFORMATION

FORM APPROVED OMB NO. 1004-0041 Expires: XXXXXX, 20XX

FOR BLM USE ONLY

State: ______________________________ Office: _____________________________ Auth. Number: ______________________

Date Filed:

INSTRUCTIONS: An applicant for a permit/lease that is based on preference should complete this form and submit to the Bureau of Land Management (BLM) along with completed forms 4130-1a (Grazing Preference Application and Preference Transfer Application) and 4130-1 (Grazing Schedule-Grazing Application). Form 4120-­8 (Assignment of Range Improvements) is used to accept assignment of interest and responsibility for maintenance of range improvements used in conjunction with the subject preference. Form 4120-8 can be obtained only from your local BLM Office. Current permittees or lessees can use Form 4130-1b to update/supersede previously submitted information. BLM retains original in case record and returns a copy to the permittee/lessee.

APPLICANT NAME:

MAILING ADDRESS:

1. APPLICANT ADDITIONAL QUALIFICATIONS STATEMENT Complete when submitting application for a new grazing permit/lease.

This section documents whether you meet requirements, besides owning or controlling base property, to qualify for grazing use on public lands. a. The applicant is a: (check only one) i. [ ] United States citizen, (or, has properly filed a valid declaration of intention to become a citizen or a valid petition for naturalization); or, ii. [ ] Group or association authorized to conduct business in the State in which the grazing use is sought, all members of which are qualified under “a(i)”; or, iii. [ ] A corporation authorized to conduct business in the State in which the grazing use is sought. For group or association, or corporation, indicate the State(s) where it is a registered business entity: ______________________________.

b. Answer the following: Has the applicant or any affiliate had any Federal grazing permit or lease cancelled for violation of the permit or lease within 36 months immediately preceding the date of this application? (See 43 CFR 4100.0-5 for definition of “affiliate.”) [ ] Yes [ ] No Has the applicant or any affiliate had any State grazing permit or lease, for lands within allotments for which a Federal grazing permit or lease is sought, cancelled for violation of the permit or lease within 36 months immediately preceding the date of this application? [ ] Yes [ ] No Is the applicant or any affiliate barred from holding a Federal grazing permit or lease by a court of competent jurisdiction? [ ] Yes [ ] No

BLM requires that you submit all relevant information we request in order to determine that you meet all qualifications, such as documentation of incorporation or of group / business association, including information regarding business organization and ownership.

(Continued on page 2)

2. OWNERSHIP AND CONTROL OF LIVESTOCK Complete with application for new permit/lease or to update information regarding an existing permit/lease. If under 43 CFR 4130.7 et seq. a livestock control agreement is required, failure to file it may result in civil and/or criminal regulatory enforcement actions.

The livestock to be grazed under the grazing permit /lease requested by this application (or under my existing permit/lease) are or will be owned by (check all that apply):  applicant (or permittee/lessee);  other party (except for sons and daughters of applicant or permittee/lessee). If checked, you must complete part 2(b).  sons and/or daughters of applicant (or of permittee/lessee); (If checked , please answer the next two questions.) i. Are the sons/daughters participating in educational or youth programs related to animal husbandry, agribusiness or rangeland management, or are they actively involved in the family ranching operation and are establishing a livestock herd with the intent of assuming part or all of the family ranching operation? [ ] Yes [ ] No ii. Will the livestock owned by the sons/daughters comprise 50 percent or less of the total number of livestock authorized to occupy public lands under the permit/lease requested by this application (or under your existing permit/lease)? [ ] Yes [ ] No If you answered no to either or both of the immediately preceding questions, you must complete part 2(b). b. Based on the information you provided in part 2(a), you are required to file with BLM the agreement that gives you (the applicant or permittee/lessee) control of the livestock that you do not own that will graze under your permit or lease. This agreement must list the kind and number of livestock subject to the agreement, state who owns them, contain the terms for their care and management, specify the duration of the agreement and be signed by the parties to the agreement. BLM must approve the agreement prior to any grazing use. You must also file with BLM the brands and other identifying marks of the livestock subject to the agreement. (See 43 CFR 4130.7 (d), (e) and (f).) This agreement is (check one): [ ] attached [ ] is not attached but will be submitted to BLM by (date): __________________. c. The brands and/or other identifying marks of the livestock that will be grazed under the permit or lease requested by this application (or the existing permit or lease) are described as follows: STATE(S) WHERE BRAND(S) IS REGISTERED:____________________________________________________________. BRAND NAME: _______________________________________________________________________________________. BRAND IS REGISTERED TO (Name): _____________________________________________________________________. IN THE SPACE BELOW, SKETCH BRAND(S), LOCATION, EARMARKS, AND ANY OTHER IDENTIFYING MARKINGS (e.g. DEWLAP / WATTLE):

3. OWNERSHIP OR CONTROL OF UNFENCED PRIVATE LAND LOCATED WITHIN BLM ALLOTMENTS Complete with application for new permit/lease or to update information regarding an existing permit/lease. This information helps BLM account for forage produced on controlled private lands when processing a grazing fee bill.

Does the applicant (or permittee/lessee) own or control (e.g. lease) unfenced private land within BLM allotments that is or will be used in conjunction with the permit or lease requested by this application? [ ] NO [ ] YES (If yes, provide the information below. If necessary, attach additional sheets. NOTE: Use Section 5 of this form to report other Federal, or State or local government grazing permits and leases). If Yes, may BLM enter this land to estimate its livestock grazing capacity and for other lawful purposes? [ ] YES [ ] LAND IS LEASED AND APPLICANT HAS NO AUTHORITY TO GRANT ENTRY PERMISSION [ ] NO (NOTE: If BLM cannot verify this land’s livestock grazing capacity, BLM will not take into account any forage for livestock that occurs on it when calculating the number of livestock BLM authorizes to graze under the permit or lease.)

PROPERTY NAME

NUMBER OF ACRES

LEGAL DESCRIPTION OF OWNED/CONTROLLED PROPERTY

LAND IS IN THIS BLM ALLOTMENT NAME and NUMBER

OWNED

LEASED

TNSHP.

RGE.

SEC.

SUBDIVISION.

MERIDIAN

4. OTHER BLM GRAZING PERMITS or LEASES Complete with application for new permit/lease or to update information regarding an existing permit/lease.

Does the applicant (or permittee/lessee) have a BLM grazing permit or lease issued by another BLM district or field office? [ ] YES (If yes, provide the information below. If necessary, attach additional sheets). [ ] NO

DISTRICT OR FIELD OFFICE NAME

ALLOTMENT NAME AND NUMBER

FORAGE AMOUNT AUTHORIZED (AUM’s)

5. OTHER FEDERAL, STATE AND LOCAL AGENCY GRAZING AUTHORIZATIONS Complete with application for new permit/lease or to update information regarding an existing permit/lease.

Does the applicant (or permittee/lessee) have a grazing permit, lease or other authorization to graze on land administered by a state or county agency, or another federal agency? [ ] YES (If yes, provide the information below. If necessary, attach additional sheets.) [ ] NO

AGENCY NAME

GRAZING AREA or ALLOTMENT NAME

LIVESTOCK NUMBER / KIND

PERIOD OF USE

FORAGE AMOUNT (AUM’s)

BEGIN DATE

END DATE

6. DESIGNATION OF AUTHORIZED REPRESENTATIVE Optional: For applicant (or permittee/lessee) to designate a representative of their choosing to conduct business with BLM. If designating an authorized representative, submit with application for new permit/lease or to update information regarding an existing permit/lease.

BLM is herein advised that until further written notice, the undersigned applicant or permittee/lessee has authorized the following person to conduct business and otherwise represent the applicant or permittee/lessee in all matters relating to grazing use on public lands within the jurisdiction of the __________________________________________ BLM Office.

Authorized Representative Information: ___________________________________________ Printed Name and Title (as applicable) ___________________________________________ Authorized Representative Signature

Correspondence Mailing Address:

Email Address:

Telephone Number(s) [e.g. Day, Night, Mobile]:

[Upon the designation of a representative and the issuance of a grazing permit or lease, grazing fee billings, official correspondence and other documents such as grazing decisions or other notices will be sent to the authorized representative acting on behalf of the permittee or lessee. An authorized representative may not apply to transfer grazing preference on a permittee/lessee’s behalf. An applicant or a permittee / lessee may change or cancel this designation at any time by submitting the change in writing to the BLM.]

7. APPLICANT (or PERMITTEE/LESSEE) SIGNATURE AND DATE

I will promptly notify BLM in writing of any changed circumstances that affect the accuracy or completeness of the information recorded on this form.

__________________________________________________________________________ ____________________________________________ Signature (Applicant or Permittee/Lessee) Date _________________________________________________ _______________________________________________________________________ Printed Name Organizational Title (If applicant or Permittee/Lesses is a Corporation or Group)

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

NOTICES

The Privacy Act and 43 CFR 2.48(d) require that you be furnished with the following information in connection with information requested by this form.

AUTHORITY: 43 U.S.C. 315, 316, and 1181d; 43 CFR 4100.

PRINCIPAL PURPOSE: The information is used to adjudicate applicant’s preference for public land or resources.

ROUTINE USES: In accordance with the Bureau of Land Management’s (BLM) System of Records Notice published in the Federal Register on December 29, 2010 [Bureau of Land Management’s

Range Management System—Interior, LLM–2; Notice To Amend an Existing System of Records; Privacy Act of 1974; as Amended], names and addresses provided by the applicant on this form will

be publically available in reports on the BLM public website.

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 the rejection and/or denial of your application.

The Paperwork Reduction Act requires us to inform you that BLM collects this information to establish preference for grazing use on public lands. 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 30 minutes 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 (1004-0041), Bureau Information Collection Clearance Officer (WO-630), 1849 C Street, N.W., Room 2134LM, Washington, D.C. 20240.

(Form 4130-1b, page 4)