Form 2920-1 - Land Use Application And Permit Page 3

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NOTICES

The Privacy Act and 43 CFR 2.48(d) require that you be furnished with the following information in

connection with the information required by this form.

AUTHORITY: 43 U.S.C. 1732 and 43 CFR Part 2920 permit collection of the information requested

by this form.

PRINCIPAL PURPOSE: The BLM uses the information in this form to process your application.

ROUTINE USES: In accordance with the System of Records titled, "Land and Minerals Authorization

Tracking System--Interior, LLM-32," disclosure outside the Department of the Interior may be made: (1) To

appropriate Federal agencies when concurrence or supporting information is required prior to granting or

acquiring a right or interest in lands or resources, (2) To Federal, State, or local agencies or a member

of the general public in response to a specific request for pertinent information, (3) To the U.S. Department

of Justice or in a proceeding before a court or adjudicative body when (a) the United States, the

Department of the Interior, a component of the Department, or when represented by the government, an

employee of the Department is a party to litigation or anticipated litigation or has an interest in such

litigation, and (b) the Department of the Interior determines that the disclosure is relevant or necessary to

the litigation and is compatible with the purpose for which the records were compiled, (4) To an appropriate

Federal, State, local, or foreign agency responsible for investigating, prosecuting, enforcing, or implementing

a statute, regulation, rule, or order, where the disclosing agency becomes aware of an indication of a violation

or potential violation of civil or criminal law or regulation, (5) To a member of Congress or a Congressional

staff member from the record of an individual in response to an inquiry made at the request of that individual,

(6) To the Department of the Treasury to effect payment to Federal, State, and local government agencies,

nongovernmental organizations, and individuals, and (7) To individuals involved in responding to a breach

of Federal data. The BLM will only disclose this information in accordance with the Freedom of Information

Act, the Privacy Act, and the provisions at 43 CFR 2.56(c).

requires us to inform you that:

The BLM collects this information to process applications for land use authorizations, in accordance with

43 CFR Part 2920.

You do not have to respond to this or any other Federal agency-sponsored information collection unless it

displays a valid OMB control number.

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 preclude the BLM's acceptance of your form.

BURDEN HOURS STATEMENT: The estimated public reporting burden for this form is 1 hour per

response for the majority of responses, including the time for reviewing instructions, gathering and maintaining

data, and completing and reviewing the form. For more complex responses, the estimated public reporting

burden is 120 hours 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 (1004-0009),

Bureau Information Collection Clearance Officer (WO-630), 1849 C Street, N.W., Washington, D.C. 20240.

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(Form 2920-1, page 3)