4710-24 Facility Requirement Form

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Form 4710-24
(July 2020)

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OMB NO. 1004.0042
Expires: February 28, 2021

UNITED STATES
DEPARTMENT OF THE INTERIOR
BUREAU OF LAND MANAGEMENT

FACILITY CERTIFICATION FORM
Last Name:

First Name:

SSN/Tax ID #:

MI:

Phone (1):

(MM/DD/YYYY)

Email Address:

Phone (2):

Mailing Address/P.O. Box:

DOB:

City:

1. How many untitled wild horses or burros are at your facility? Adopted (Untitled)

State:
Foster

Zip:

Other (BLM approved programs)

2. Additional request to adopt more than four untitled animals*: # of additional animals requested to adopt

(continue to #4)

3. Caring for animals outside of BLM Corrals (For fostering, volunteering or partnership programs ONLY):
a) Are you interested in training horses or burros (if applicable)?
b) If yes, how many? Horses

Yes

No

Burros

4. Physical Address of your facility (if different than mailing address above):
Describe your facility: (Facility refers to an enclosed area such as a corral, barn, stall, etc. Materials used may include pipe panels, wood post, planks, horse fence, etc.)
a) Corral: Length

Width

Height of Corral

Materials used in Corral
b) Shelter: Type of Shelter
Width
Yes

Supplemental Feed:

d) Water: Is there access to a water source?
e) Trailer: Type of trailer –

Stock

If yes, can they be secured back?
Yes

Included within corral square footage?

Yes
Horse

Yes
No

No

Directions to the facility:

(Continued on Page 2)

No

Amount per day:

Water source:

Homemade

Well

City

Automatic

Capacity (No. of animals):

Other
Dividers?

Yes

No

No (Additional restrictions apply, please contact BLM)

If not, describe the type?

Draw a map to the facility (from the nearest major highway) &
provide directions to your location using the space below.
N

Yes

If not, how is it accessible?

No

c) Feed: Type of hay or pasture:

Is trailer covered?

Gate Width

Materials used in Shelter (if applicable)

Length
Attached to Corral?

Gate Height

Materials used in Gate

Draw a layout of the corral(s) and shelter(s) & provide a brief
description using the space below.
N

Provide a description of the facility layout:

(Form 4710-24)

*This form is required in addition to the application for private maintenance for the certification of caring for more than four wild horses
and burros. An individual or group of individuals can request to adopt more than four wild horses or burros in a 12-month period.
This request is initiated by completing this form stating their ability to humanely care for the animals and includes a description of the
facilities, including corral and shelter sizes, feed, water and trailer information. The form should be certified by a local humane official,
veterinarian, cooperative extension agent, or a similarly qualified person. Once the form is completed, the authorized officer will review,
follow-up as needed, conduct an inspection to verify that the applicant’s facilities are adequate to care for the number of animals requested
and provide a decision.
(Date)

(Applicant Signature)

CERTIFICATION
I,

(Certifying Individual – Print Name)

, am qualified by education, training and/or experience to assess the adequacy of the facility for

maintaining adopted wild horses or burros.

(Date)

(Certifying Signature)

BLM Official Use Only
The facility described based on BLM requirements is:

(BLM Authorized Officer Signature)

adequate

inadequate

(Date)

to care for the number of animals requested.

# Facility Approved (total # of Animals)

NOTICES
The Privacy Act requires that you be furnished the following information in connection with information required by this application.
AUTHORITY: 16 U.S.C. 1333 and 31 U.S.C. 7701.
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 the rejection and/or denial of your facility certification
request.
PRINCIPAL PURPOSE: The BLM will use this information when certifying your facility for the care of wild horses or burros. BLM will
use your driver’s license and social security numbers as necessary for communication purposes.
ROUTINE USES: The primary uses of the information are to:
1) Identify adopters who are requesting to care for more than four wild horses or burros;
2) Document the certification or rejection of the request to care for wild horses or burros;
3) Monitor compliance with laws/regulations concerning maintenance of wild horses or burros outside of BLM care;
4) Identify contractors/employees/volunteers/service providers/adopters required to perform program functions i.e., veterinarians,
farriers, the U.S. Forest Service (USFS) and the Animal and Plant Health Inspection Service (APHIS);
5) Provide necessary program management information to other agencies involved in management of wild horses and burros;
6) Identify and assign level of system access required by BLM, USFS and APHIS wild horse and burros program personnel; and
7) Authorize the disclosure of records to individuals involved in responding to a breach of Federal data.

(Continued on Page 3)

(Form 4710-24, Page 2)

PAPERWORK REDUCTION ACT NOTICE
The Paperwork Reduction Act of 1995 (44 U.S.C. 3501 et seq.) requires us to inform you that:
The BLM collects this information in accordance with the statutes and regulations listed above, and for the purposes listed above.
Submission of the requested information is necessary 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.

List of Minimum Shelter Requirements by State:
MINIMUM REQUIREMENT*

EXAMPLE

Colorado, Idaho, Kansas,
Nevada, New Mexico,
Oklahoma,
Oregon/Washington (east of
the Cascade Mountains),
Texas, Utah
Nebraska, Wyoming

Shelter shall be available to mitigate
the effects of inclement weather and
temperature extremes. The requirement
is at the discretion of the authorized
officer and will vary dependent on the
severity of weather in the region.
Natural cover or man-made structure
that provides a wind break.

Natural cover (tree, etc.)
or man-made structure
(plywood or other
material on side of
corral, stall, etc.)

Alabama, Arizona, Arkansas,
Florida, Georgia, Kentucky,
Louisiana, Mississippi, North
Carolina, South Carolina,
Tennessee, Virginia

Natural cover or man-made structure
that provides shade.

California,
Oregon/Washington (west of
the Cascade Mountains)

A two (2)-sided shelter with a roof.

STATE

Alaska, Connecticut,
A three (3)-sided shelter with a roof.
Delaware, Illinois, Indiana,
Heated water source (Alaska only).
Iowa, Maine, Maryland,
Massachusetts, Michigan,
Minnesota, Missouri, Montana,
New Hampshire, New Jersey,
New York, North Dakota,
Ohio, Pennsylvania, Rhode
Island, South Dakota,
Vermont, West Virginia, and
Wisconsin

Tree (etc.) or structure
with a side (plywood on
side of corral, stall, etc.)
Tree (etc.) or structure
with a roof (wood, metal,
etc.)

Structure with sides and
a roof (wood, metal, etc.)
Structure with sides, a
back, and a roof (wood,
metal, etc.)

* These requirements are in addition to state, county, and local animal health and welfare laws
and regulations for the area the animal resides.

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. Direct comments regarding the burden estimate or any other
aspect of this form to U.S. Department of the Interior, Bureau of Land Management (1004-0042), Bureau Information Collection
Clearance Officer, (WO-630), 1849 C Street, N.W., Washington, D.C. 20240.

(Form 4710-24, Page 3)