Form 4130-5 Grazing Form

Form 4130-5	UNITED STATES	FORM APPROVED
(xxxx 20xx)	DEPARTMENT OF THE INTERIOR	OMB NO. 1004-0041
	BUREAU OF LAND MANAGEMENT	Expires: xxxxxxx xx, 20xx
	ACTUAL GRAZING USE REPORT

Dear Grazing Operator:

In accordance with the terms and conditions of the permit or lease which authorizes your grazing use, please complete this form and return to the Field Office within 15 days after completing your authorized grazing use (43 CFR 4130.3-2(d)). Use a separate line for each date that you either turned livestock into or took livestock out of an allotment or pasture. Providing accurate actual use records is needed to evaluate the effectiveness of present management.

PLEASE USE SEPARATE FORM FOR EACH ALLOTMENT USED

ACTUAL GRAZING USE						FOR BLM USE ONLY
ALLOTMENT NAME AND NUMBER:						CALCULATION OF AUM’S GRAZING USE
PASTURE (Name and Number)	KIND or CLASS OF LIVESTOCK (CC – Cow/Calf, B – Bulls, YL – Yearlings, etc.)	GRAZING USE (dates & number of animals)				% PL USE	AUM’S
		DATES and # OF HEAD TURNED INTO PASTURE Date # of Head		DATES and # OF HEAD TAKEN OFF PASTURE Date # of Head

I CERTIFY That this is a complete and accurate report of my grazing use.
Signature of Permittee/Lessee	Printed Name of Permittee/Lessee	Date
Title 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 statement or presentations as to any matter within its jurisdiction.

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RECORD OF LIVESTOCK LOSSES

REASONS FOR LOSS - Poisonous plants, predation, weather, disease, theft, unknown.	NUMBER AND KIND OR CLASS OF LIVESTOCK	DATE

Remarks (Include other information such as range conditions and/or improvement notes, or unauthorized use by strays, etc.):

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, 1701, 1901, 1181d, and 43 CFR 4100.

PRINCIPAL PURPOSE: Information will be used to document the actual amount of livestock grazing use on the public lands to calculate your billing, and to

help evaluate the effectiveness of management actions in meeting resource management objectives.

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: Disclosure of the information is required to obtain or retain a benefit. Failure to submit all of the requested information or to complete this form may result in delayed payment due the Government or insufficient data needed to manage the program.

The Paperwork Reduction Act requires us to inform you that: BLM collects this information to document the purpose, need, and other information for

grazing use on the public lands. Response to this request is required to obtain or retain a benefit. 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 15 minutes per response, including the time for reviewing instructions, gathering and maintaining data, and completing and reviewing the form. Direct 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 4130-5, page 2