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FORM APPROVED: ACTUAL GRAZING USE REPORT UNITED STATES (Bureau of Land Management - Main Domain)

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Form 4130-5
(January 2018)
UNITED STATES
DEPARTMENT OF THE INTERIOR
BUREAU OF LAND MANAGEMENT
FORM APPROVED
OMB NO. 1004-0041
Expires: 12/31/2020
ACTUAL GRAZING USE REPORT
Dear Grazing Operator:
In accordance with the terms and conditions of the permit or lease which authorizes your grazing use, please complete this form
and return to the Field Ofce within 15 days after completing
your authorized grazing use (43 CFR 4130.3-2(d)). Use a separate line for each date that you either turned livestock into or took livestock
out of an allotment or pasture. Providing accurate actual use records is needed to evaluate the effectiveness of present management.
PLEASE USE SEPARATE FORM FOR EACH ALLOTMENT USED
ACTUAL GRAZING USE FOR BLM USE ONLY
ALLOTMENT NAME AND NUMBER:
CALCULATION OF AUM’S
GRAZING USE
PASTURE
(Name and Number)
KIND or CLASS
OF LIVESTOCK
(CC – Cow/Calf,
B – Bulls, YL –
Yearlings, etc.)
GRAZING USE
(dates & number of animals)
% PL USE AUM’S
DATES and # OF HEAD
TURNED INTO PASTURE
Date # of Head
DATES and # OF HEAD
TAKEN OFF PASTURE
Date # of Head
I CERTIFY that this is a complete and accurate report of my grazing use.
Signature of Permittee/Lessee Printed Name of Permittee/Lessee Date
Title U.S.C. Section 1001, makes it a crime for any person knowingly and willfully to make to any department or agency of the United States any false,
ctitious, or fraudulent statement or presentations as to any matter within its jurisdiction.
(Continued on Page 2)
(Form 4130-5)
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RECORD OF LIVESTOCK LOSSES
REASONS FOR LOSS - Poisonous plants,
predation, weather, disease, theft, unknown.
NUMBER AND KIND OR CLASS OF LIVESTOCK DATE
Remarks (Include other information such as range conditions and/or improvement notes, or unauthorized use by strays, etc.):
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, 1701, 1901, 1181d, and 43 CFR 4100.
PRINCIPAL PURPOSE: Information will be used to document the actual amount of livestock grazing use on the public lands to calculate
your billing, and to help evaluate the effectiveness of management actions in meeting resource management objectives.
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: Disclosure of the information is required to obtain or retain a benet. Failure to
submit all of the requested information or to complete this form may result in delayed payment due the Government or insufcient data
needed to manage the program.
The Paperwork Reduction Act requires us to inform you that: BLM collects this information to document the purpose, need, and other
information for grazing use on the public lands. Response to this request is required to obtain or retain a benet. 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 15 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 (1004-0041), Bureau
Information Collection Clearance Ofcer (WO-630), 1849 C Street, N.W., Room 2134LM, Washington, D.C. 20240.
(Form 4130-5, page 2)
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FORM APPROVED: ACTUAL GRAZING USE REPORT UNITED STATES (Bureau of Land Management - Main Domain)

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Completed 19 July 2020

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