Form 4130-1b - Grazing Application Supplemental Information Page 4

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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.

Correspondence Mailing Address:

UTHORIZED

EPRESENTATIVE

NFORMATION

___________________________________________

Printed Name and Title (as applicable)

Email Address:

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

___________________________________________

Authorized Representative Signature

[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.

__________________________________________________________________________

____________________________________________

(Applicant or Permittee/Lessee)

IGNATURE

ATE

_________________________________________________

_______________________________________________________________________

(If applicant or Permittee/Lesses is a Corporation or Group)

RINTED

AME

RGANIZATIONAL

ITLE

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)