Fillable FORM APPROVED: Contracting Ofcer. (If Yes, give date (Bureau of Land Management - Main Domain)

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FORM APPROVED: Contracting Ofcer. (If Yes, give date (Bureau of Land Management - Main Domain)

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UNITED STATES
DEPARTMENT OF THE INTERIOR
BUREAU OF LAND MANAGEMENT
EXPORT DETERMINATION
FORM APPROVED
OMB No. 1004-0058
Expires: November 30, 2022
Location of facility where Federal Timber is
expected to be processed
Timber sale applicant forwards information to
Contracting Ofcer.
INSTRUCTIONS
In compliance with requirements of 43 CFR 5424.1,
We hereby submit the following information:
I
(1)
Have you exported private timber from lands tributary to the above processing facility within the last 12 months?
Yes
No
(If “Yes,” give date of last export sale.)
a. Export (date)
(2)
Provide names of afliates * who have exported private timber from lands tributary to the above processing facility within
the last 12 months and date of last export sales.
Export date
a. Afliate
Export date
b. Afliate
c. Afliate Export date
*See 43 CFR 5400.0-5
Name of Firm
Signature of Signing Ofcer
Title
Date
NOTICES
The Privacy Act and 43 CFR 2.48(d) require that you be furnished with the following information in connection with the information requested
by this form.
AUTHORITY: 43 CFR Part 5420 permit collection of the information requested by this form.
PRINCIPAL PURPOSE: The BLM uses the information in this form to determine whether Federal timber has been substituted for exported
unprocessed private timber.
ROUTINE USES: Timber sale purchaser provides information regarding their export of private timber.
EFFECT OF NOT PROVIDING INFORMATION: Submission of the requested 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 delay or preclude the BLM’s acceptance of your form.
The Paperwork Reduction Act requires us to inform you that:
The BLM collects this information to determine whether Federal timber has been substituted for exported private timber in accordance with 43
CFR 5421.1 and 5424.0-6(e).
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: The estimated public reporting burden for this form is 1 hour per response for a majority of responses,
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
(1004-0058), Bureau Information Collection Clearance Ofcer, 1849 C Street, N.W., Room 2134 LM, Washington, D.C. 20240.
Form 5450-17 (June 1, 2016)
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FORM APPROVED: Contracting Ofcer. (If Yes, give date (Bureau of Land Management - Main Domain)

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Completed 19 July 2020

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