Form 4710-25
(June 2020)
UNITED STATES
DEPARTMENT OF THE INTERIOR
BUREAU OF LAND MANAGEMENT
NOTE: THIS IS A
CONTRACT, RETAIN
WITH OTHER LEGAL
RECORDS.
ADOPTION INCENTIVE AGREEMENT
Last Name: First Name: Middle Name: Email:
Address: City: State: Zip:
Animal Identication
(Freezemark/Signalment Key)
Incentive
Amount (1st)
Adoption
Date
Incentive
Amount (2nd)
Title
Date
Cost Code
Source Year:
BOC: 252Z
#1
$ $
LLWO260000 L10600000.HG0000 LXSIADOPTWHB
#2
$ $
LLWO260000 L10600000.HG0000 LXSIADOPTWHB
#3
$ $
LLWO260000 L10600000.HG0000 LXSIADOPTWHB
#4
$ $
LLWO260000 L10600000.HG0000 LXSIADOPTWHB
(1st Payment Total)
$ $
(2nd Payment Total)
I _____________________________ choose to opt out of the BLM adoption incentive program and forfeit/waive any incentive payments from the BLM.
OR
Please initial the terms that apply to all wild horses and burros adopted under this BLM adoption incentive agreement.
Initial: __________
Initial: __________
Initial: __________
Initial: __________
Initial: __________
Initial: __________
Initial: __________
Initial: __________
Initial: __________
Initial: __________
I have read and understand the terms of adoption, prohibited acts, and title qualications, incentive payments, and ineligible
participants provided on page 2.
I understand that I can maintain a maximum of four untitled animals through the adoption incentive program; however, as each
participating animal is titled, I become eligible to adopt additional animal(s) through the adoption incentive program.
In accordance with the terms of adoption, I authorize BLM employees and other BLM approved individuals to conduct
compliance inspections on adopted animals participating in the incentive program.
I understand I will lose my eligibility to participate in the adoption incentive program in the future if I return two or more animals
within any 12 month period under 43 CFR 4750.4-3, which states “An adopter may request to terminate his/her responsibility for
an adopted animal by submitting a written relinquishment of the Private Maintenance and Care Agreement for that animal…”.
I understand returning any animal(s) as stated above after receiving adoption incentive payments will result in a nancial liability
to the BLM.
I hereby authorize electronic funds transfers to my account at the nancial institution provided. NOTE: All incentive payments
are made via electronic funds transfer.
I understand that I am responsible to submit one Adoption Incentive Agreement (4710-25), ACH Form (SF-3881) and title
application (4710-18) for adopted animals within 60 days of adoption and title dates to receive incentive payments.
I certify that I am not a BLM employee, spouse or domestic partner of a BLM employee, BLM contractor or BLM partner.
I _____________________ (Print Name) understand that failure to comply with the following terms (compliance will be judged
solely by the BLM) may result in the cancellation of this BLM adoption incentive agreement, repossession of the animals,
disapproval of request for adoption of additional animals as well as eligibility to participate in the BLM adoption incentive
program. I further understand that in the event any of the above actions result in a nancial liability to BLM, the BLM
will pursue collection of a portion or all of the incentive payment(s) from me by all appropriate methods, in accordance
with the Federal Claims Collection Act and the Debt Collection Improvement Act (DCIA) of 1996 (31 U.S.C 3701 et seq).
Under penalty of prosecution for violating 18 U.S.C. 1001, which makes it a Federal crime to make false statements to any
agency of the United States, I hereby certify that I will provide humane care for any animals that I adopt and will not sell or
transfer ownership of them to any person or organization that intends to resell, trade, or give away such animals for slaughter or
processing into commercial products.
Adopter Signature: __________________________________________ BLM authorized ocer: __________________________________________
(Continued on Page 2)
(Form 4710-25)
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PROHIBITED ACTS
(a) Maliciously or negligently injuring or harassing a wild horse or burro;
(b) Treating a wild horse or burro inhumanely;
(c) Removing or attempting to remove a wild horse or burro from the
public lands without authorization from the BLM;
(d) Destroying a wild horse or burro without authorization from the BLM,
except as an act of mercy
(e) Selling or attempting to sell a wild horse or burro or its remains;
(f) Branding a wild horse or burro;
(g) Removing or altering a freeze mark on a wild horse or burro;
(h) Violating an order, term, or condition established by the BLM under
this part;
(i) Commercially exploiting a wild horse or burro;
Any person who commits a prohibited act is subject to a fine of not
more than $2,000 or imprisonment for not more than one year, or both,
for each violation.
TERMS OF ADOPTION
The following terms apply to all wild horses and burros adopted under the
Private Maintenance and Care Agreement:
(a) Adopters are nancially responsible for providing proper care;
(b) Adopters are responsible, as provided by State law, for any personal
injury, property damage, or death caused by animals in their care, for
pursuing animals that escape or stray, and for costs of recapture;
(c) Adopters must not transfer animals for more than 30 days to another
location or to the care of another individual without the prior approval
of the BLM;
(d) Adopters must make animals available for physical inspection within
7 days of receipt of a written request by the BLM;
(e) Adopters must notify the BLM within 7 days of discovery of an
animal’s death, theft or escape;
(f) Adopters must notify the BLM within 30 days of any change in the
adopters address;
(g) Adopters must dispose of remains in accordance with applicable
sanitation laws;
(h) Title will remain with the Federal Government for at least 1 year after
the Private Maintenance and Care Agreement is executed and until a
Certicate of Title is issued by the BLM;
(i) Adoption fees are non-refundable; and
(j) Adopters are entitled to a replacement, if, within 6 months of the
adoption date, the animal dies or is required to be destroyed due to
a condition that existed at the time of adoption and if the adopter
provides a veterinarian statement that certies that reasonable care
would not have corrected the condition. All replacement animals will
be handled as a refund (completed within 2 weeks of notication),
or a voucher for a replacement animal will be cbe applied to more
than one animal; is non-transferable; has to be redeemed at the same
type of event as the original adoption; and does not give the adopter
any kind of preferential treatment. Additionally, the amount of the
voucher has to be redeemed all at once; non-used funds are forfeited;
and bids above the voucher amount are due in full at the time of the
adoption. This policy will only apply to replacement animals, and not
repossessions or reassignments.
TITLE QUALIFICATIONS, INCENTIVE PAYMENTS and INELIGIBILE PARTICIPANTS
A person may receive title to as many as four (4) wild horses or burros per
12 month period provided the following qualications are met:
Title applicants participating in the BLM Adoption Incentive Program are
required to submit one Adoption Incentive Agreement (4710-25), ACH
Form (SF-3881) and title application (4710-18) per adopted animal within
60 days of adoption and title dates to receive incentive payments.
The applicant has had the horses or burros assigned by a Private
Maintenance and Care Agreement for a minimum of 12 months.
BLM employees, spouses or domestic partners of BLM employees, BLM
contractors, and BLM partners are not eligible to participate in the BLM
adoption incentive program.
At the end of the 12 month period, the applicant has submitted written
certication of a qualied individual attesting, to the best of his/her
knowledge, that the adopted animals are receiving proper care.
NOTICE
The Privacy Act and the regulation at 43 CFR 2.48 (d) require 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.
PRINCIPAL PURPOSE: The BLM will use this information to process
your adoption incentive agreement for wild horses or burros. BLM will
use your nancial information, drivers license and social security numbers
for debt collection purposes under the authority of the Debt Collection
Improvement Act, 31 U.S.C. 7701.
ROUTINE USES: The primary uses of the information are to:
(1) Identify individuals who have applied to obtain custody of a wild
horse or burro through adoption or sale;
(2) Document the rejection, suspension, or granting of the request for
adoption or sale;
(3) Monitor compliance with laws / regulations concerning maintenance
of adopted animals;
(4) Identify contractors / employees / volunteers / service providers
required to perform program functions;
(5) Provide necessary program management information to other agencies
involved in management of wild horses and burros on public lands,
i.e., the U.S. Forest Service (USFS) and the Animal and Plant Health
Inspection Service (APHIS);
(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.
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 application.
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
agencysponsored information collection unless it displays a currently valid
OMB control number.
(Form 4710-25, Page 2)