Permittee Report of Road Use

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Permittee Name/Contact/Bill Address: ↓

United States Department of the Interior
Bureau of Land Management - Oregon State Office
PERMITTEE REPORT OF ROAD USE
Permit No.:↓

Serial No.:↓

Period From↓:

Period To↓:

Form OR 2812-6 (October 2026)
OMB 1004-0168; Expiration 10/31/2029

Page 1 of _____

(for this reporting period)
↓BLM responsible for finalizing this portion↓:

↓Permittee required to complete this portion↓:
Material Hauled From:

Road Use Fees

Maintenance Fees

Surface
Replacement Fees

Quantity
hauled
(MBF in
Long
Log)*

Alloc. or
NonFee/
Amount
Length
Alloc.
Road Use Due (NTE
Fee/
MBF/
Permittee Project Name
Road
used
Surface
(A or
Fee/MBF Current Def. MBF/Mi. Amount
Mi.
T. R. Sec.
BLM Road No. Segment
(optional)
(Mi.)
Type
Non)
($)**
Used
Due
Used Amount Due
Bal.)
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
SUBTOTALS FROM PAGE 1
$0.00
$0.00
$0.00
SUBTOTALS FROM PAGE 2
$0.00
$0.00
$0.00
TOTAL ALL PAGES (AMOUNTS TO BE BILLED)
$0.00
$0.00
$0.00
PERMITTEE CERTIFICATION (Check one):
BLM Verification:
I certify that this Report of Road Use (all pages) is true and that, to the best of my knowledge,
The hauling data in this Report of Road Use is verified. Bill can be
prepared.
is a complete statement of our hauling on U.S. roads during the above reporting period, or
I certify that no hauling occurred on any U.S. roads during the above reporting period.
Delegated BLM Official
Permittee Signature***

Title

Date

Date

*To report "Other Special Road Use" haul, enter the number of vehicles in the Quantity Hauled column and the appropriate fee per/vehicle mile into the Road Maintenance Fee/MBF Column.
**For Reciprocal ROW: fees are calculated per MBF. If permit is system fee--then it is a negotiated fee/MBF. If a unilateral permit, use state-wide RUF/MBF.
***Title 18 U.S.C. Section 1001 makes it a crime for any person to knowingly make to any department or agency of the United States any false, ficticious, or fraudulent statements of
representation as to any matter within its jurisdiction.
Note: The Paperwork Reduction Act of 1995 requires us to inform you that: This information is being collected to determine road use and maintenance fees and verify other information
relevant to operations under your right-of-way permit. The information is requried as a condition of your right-of-way permit and the regulations in 43 CFR 2812.8-1. Failure to submit this
information may be grounds for suspension or termination of your permit. BLM may not sponsor, and you are not required to respond to, a collection of information that does not display a
current valid OMB control number. Public reporting burden for this form is estimated to average 1 hour per response, including time for reviewing instructions, gathering and maintaining
data, and completing and reviewing this 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, Bureau Clearance Officer, WO-630 (1004-0168), 1849 C Street, N.W., Mail Stop 4011LS, Washington, D.C. 20240.

United States Department of Interior
Bureau of Land Management - Oregon State Office
PERMITTEE REPORT OF ROAD USE
(CONTINUATION SHEET)
Permit No. (one permit per report unless all
are "no haul"):

Permit No.↓

Serial No. ↓

Period From↓:

↓Permittee required to complete this portion↓:
Material Hauled From:

T.

R. Sec.

Permittee Project
Name (optional)

Form OR 2812-6 (October 2026)
OMB 1004-0168; Expiration 10/31/2029

Period To↓:

Page _____ of _____

(for this reporting period)
↓BLM responsible for finalizing this portion↓:
Road Use Fees

Surface
Maintenance Fees Replacement Fees

Alloc. or
NonAmount
Fee/
Alloc.
Road Use Due (NTE
Fee/
MBF/
BLM Road
Road
(A or
Fee/MBF Current MBF/Mi. Amount
Mi.
No.
Segment
Non)
($)**
Def. Bal.)
Used
Due
Used
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
TOTALS THIS PAGE (BLM TRANSFER TO PAGE 1)→
Quantity
Length
hauled
used
(MBF in Surface
(Mi.) long log)*
Type

PERMITTEE CERTIFICATION for this continuation sheet:
← Initial here to indicate that certification on page one applies to this page as well.

Amount
Due
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00

BLM Verification:
The hauling data in this Report of Road Use is verified. Bill can be
prepared.

Delegated BLM Official

Date

*To report "Other Special Road Use" haul, enter the number of vehicles in the Quantity Hauled column and the appropriate fee per/vehicle mile into the Road Maintenance
Fee/MBF Column.
**For Reciprocal ROW: fees are calculated per MBF. If permit is system fee--then it is a negotiated fee/MBF. If a unilateral permit, use state-wide RUF/MBF.