Fillable Form 4120-6 - Cooperative Range Improvement Agreement (Page 4 of 4) in pdf

Form 4120-6 - Cooperative Range Improvement Agreement Page 4

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LOCATION PLAT

Sec.

, T.

, R.

Mer.

Scale

inches equals one mile

NOTICES

The Privacy Act and 43 CFR 2.48(d) require that you be furnished the following information in connection with the information requested by this form.

AUTHORITY: 43 U.S.C. 315, 43 U.S.C. 1752, 43 U.S.C. 1904 and subpart 4120 permit collection of the information requested by this form.

PRINCIPAL PURPOSE: The BLM will use the information you provide to develop a cooperative agreement for the construction, use, and maintenance of range

improvements on its public lands. The information will be used to document specific participation of each cooperator on the range improvement(s) to be accomplished under the

cooperative agreement.

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 publicly 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 the requested

information or to complete this form may result in delay or rejection and/or denial of your application.

The Paperwork Reduction Act requires that you be furnished the following information in connection with the information requested by this form: BLM collects this

information to authorize range improvements on public lands. Response to this request is required in order 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 valid OMB Control Number.

BURDEN HOURS STATEMENT: Public reporting burden for this form is estimated to average 2 hours 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 (1004-0019), Bureau Information Collection Clearance Officer (WO-630), 1849 C Street, N.W., Room 2134LM, Washington, D.C.

20240.

(Form 4120-6, page 4)

Form 4120-6 - Cooperative Range Improvement Agreement Page 4

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