Fillable Form 4710-24: FACILITY CERTIFICATION FORM UNITED STATES DEPARTMENT (Bureau of Land Management - Main Domain)

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Form 4710-24: FACILITY CERTIFICATION FORM UNITED STATES DEPARTMENT (Bureau of Land Management - Main Domain)

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Form 4710-24
(July 2020)
UNITED STATES
DEPARTMENT OF THE INTERIOR
BUREAU OF LAND MANAGEMENT
OMB NO. 1004.0042
Expires: February 28, 2021
FACILITY CERTIFICATION FORM
Last Name: First Name: MI: DOB:
(MM/DD/YYYY)
SSN/Tax ID #:
Phone (1): Phone (2):
Email Address:
Mailing Address/P.O. Box: City: State: Zip:
1. How many untitled wild horses or burros are at your facility? Adopted
(Untitled) Foster Other (BLM approved programs)
(continue to #4)
2. Additional request to adopt more than four untitled animals*: # of additional animals requested to adopt
3. Caring for animals outside of BLM Corrals (For fostering, volunteering or partnership programs ONLY):
a) Are you interested in training horses or burros (if applicable)?
Yes No
b)
If yes, how many? Horses Burros
4. Physical Address of your facility
(if dierent than mailing address above):
Describe your facility:
(Facility refers to an enclosed area such as a corral, barn, stall, etc. Materials used may include pipe panels, wood post, planks, horse fence, etc.)
a)
Corral: Length
Width Height of Corral Gate Height Gate Width
Materials used in Corral Materials used in Gate
b)
Shelter: Type of Shelter
Materials used in Shelter
(if applicable)
Length Width Included within corral square footage?
Yes
No
Attached to Corral?
No
If not, how is it accessible?
Yes
c)
Feed: Type of hay or pasture: Supplemental Feed: Amount per day:
d)
Water: Is there access to a water source?
Yes No
Water source:
Well City Automatic Other
e)
Trailer: Type of trailer –
Stock Horse Homemade
Capacity (No. of animals): Dividers?
Yes No
If yes, can they be secured back?
Yes
No
(Additional restrictions apply, please contact BLM)
Is trailer covered?
Yes No
If not, describe the type?
Draw a map to the facility (from the nearest major highway) &
provide directions to your location using the space below.
Draw a layout of the corral(s) and shelter(s) & provide a brief
description using the space below.
N N
Directions to the facility: Provide a description of the facility layout:
(Continued on Page 2)
(Form 4710-24)
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(Form 4710-24, Page 2)
, am qualied by education, training and/or experience to assess the adequacy of the facility for
maintaining adopted wild horses or burros.
*This form is required in addition to the application for private maintenance for the certication of caring for more than four wild horses
and burros. An individual or group of individuals can request to adopt more than four wild horses or burros in a 12-month period.
This request is initiated by completing this form stating their ability to humanely care for the animals and includes a description of the
facilities, including corral and shelter sizes, feed, water and trailer information. The form should be certied by a local humane ocial,
veterinarian, cooperative extension agent, or a similarly qualied person. Once the form is completed, the authorized ocer will review,
follow-up as needed, conduct an inspection to verify that the applicant’s facilities are adequate to care for the number of animals requested
and provide a decision.
(Applicant Signature)
(Date)
CERTIFICATION
I,
(Certifying Individual – Print Name)
(Certifying Signature)
(Date)
BLM Ocial Use Only
The facility described based on BLM requirements is: adequate inadequate to care for the number of animals requested.
(BLM Authorized Ocer Signature)
(Date)
# Facility Approved (total # of Animals)
NOTICES
The Privacy Act requires that you be furnished the following information in connection with information required by this application.
AUTHORITY: 16 U.S.C. 1333 and 31 U.S.C. 7701.
EFFECT OF NOT PROVIDING INFORMATION: Submission of the requested information is necessary to obtain or retain a benet. Failure
to submit all of the requested information or to complete this form may result in the rejection and/or denial of your facility certication
request.
PRINCIPAL PURPOSE: The BLM will use this information when certifying your facility for the care of wild horses or burros. BLM will
use your driver’s license and social security numbers as necessary for communication purposes.
ROUTINE USES: The primary uses of the information are to:
1) Identify adopters who are requesting to care for more than four wild horses or burros;
2) Document the certication or rejection of the request to care for wild horses or burros;
3) Monitor compliance with laws/regulations concerning maintenance of wild horses or burros outside of BLM care;
4) Identify contractors/employees/volunteers/service providers/adopters required to perform program functions i.e., veterinarians,
farriers, the U.S. Forest Service (USFS) and the Animal and Plant Health Inspection Service (APHIS);
5) Provide necessary program management information to other agencies involved in management of wild horses and burros;
6) Identify and assign level of system access required by BLM, USFS and APHIS wild horse and burros program personnel; and
7) Authorize the disclosure of records to individuals involved in responding to a breach of Federal data.
(Continued on Page 3)
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(Form 4710-24, Page 3)
PAPERWORK REDUCTION ACT NOTICE
The Paperwork Reduction Act of 1995 (44 U.S.C. 3501 et seq.) requires us to inform you that:
The BLM collects this information in accordance with the statutes and regulations listed above, and for the purposes listed above.
Submission of the requested information is necessary 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.
List of Minimum Shelter Requirements by State:
STATE MINIMUM REQUIREMENT* EXAMPLE
Colorado, Idaho, Kansas,
Nevada, New Mexico,
Oklahoma,
Oregon/Washington (east of
the Cascade Mountains),
Texas, Utah
Shelter shall be available to mitigate
the eects of inclement weather and
temperature extremes. The requirement
is at the discretion of the authorized
ocer and will vary dependent on the
severity of weather in the region.
Natural cover (tree, etc.)
or man-made structure
(plywood or other
material on side of
corral, stall, etc.)
Nebraska, Wyoming Natural cover or man-made structure
that provides a wind break.
Tree (etc.) or structure
with a side (plywood on
side of corral, stall, etc.)
Alabama, Arizona, Arkansas,
Florida, Georgia, Kentucky,
Louisiana, Mississippi, North
Carolina, South Carolina,
Tennessee, Virginia
Natural cover or man-made structure
that provides shade.
Tree (etc.) or structure
with a roof (wood, metal,
etc.)
California,
Oregon/Washington (west of
the Cascade Mountains)
A two (2)-sided shelter with a roof. Structure with sides and
a roof (wood, metal, etc.)
Alaska, Connecticut,
Delaware, Illinois, Indiana,
Iowa, Maine, Maryland,
Massachusetts, Michigan,
Minnesota, Missouri, Montana,
New Hampshire, New Jersey,
New York, North Dakota,
Ohio, Pennsylvania, Rhode
Island, South Dakota,
Vermont, West Virginia, and
Wisconsin
A three (3)-sided shelter with a roof.
Heated water source (Alaska only).
Structure with sides, a
back, and a roof (wood,
metal, etc.)
* These requirements are in addition to state, county, and local animal health and welfare laws
and regulations for the area the animal resides.
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. Direct comments regarding the burden estimate or any other
aspect of this form to U.S. Department of the Interior, Bureau of Land Management (1004-0042), Bureau Information Collection
Clearance Ocer, (WO-630), 1849 C Street, N.W., Washington, D.C. 20240.
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Form 4710-24: FACILITY CERTIFICATION FORM UNITED STATES DEPARTMENT (Bureau of Land Management - Main Domain)

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Completed 26 January 2021

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