Form 5510-1
(April 2017)
UNITED STATES
DEPARTMENT OF THE INTERIOR
BUREAU OF LAND MANAGEMENT
FREE USE APPLICATION AND PERMIT
VEGETATIVE MATERIAL
APPLICATION
FORM APPROVED
OMB NO. 1004-0001
Expires: December 31, 2019
Permit Number
Expiration Date
District
Name of applicant
Address (include zip code)
Kind of material
Units
Estimated quantity
Give legal land description
SUBDIVISIONSECTIONRANGETOWNSHIP
State of County of
Materials are to be used for
I HEREBY AGREE TO COMPLY WITH the special conditions as set forth below. I CERTIFY That the: (a) materials to be removed are to be used for the purpose noted above;
(b) none of the materials removed are to be sold or bartered (Alaska subsistence exempt); (c) removal of materials can begin only upon receipt of an approved copy of this
permit; and, (d) the Bureau of Land Management (BLM) must be notied upon completion of removal.
I CERTIFY That I am a citizen of the United States, and of the age of majority in the State in which I reside.
I FURTHER CERTIFY That the statements made by me in this application are true, complete, and correct to the best of my knowledge and belief and are made in good faith.
(Date)
(Signature of Applicant)
Title 18 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 statements or
representations as to any matter within its jurisdiction.
The Privacy Act and the regulations in 43 CFR 2.223(d) require that you be furnished with the following information:
• AUTHORITY: 16 U.S.C. 604 - 607a and 612 and 43 CFR Part 5510.
• PRINCIPAL PURPOSE: BLM uses the information to maintain an inventory of vegetation information and to adjudicate your rights to remove vegetative resources under the Free Use Regulations
at 43 CFR Part 5510.
• ROUTINE USES: BLM will disclose the information on this form pursuant to the regulations in 43 CFR 2.56.
• EFFECT OF NOT PROVIDING THIS INFORMATION: Submission of the requested information is necessary to obtain a benet. Failure to submit all of the requested information or to
complete this form may result in delay or preclude the BLM’s acceptance of the application.
PERMIT SPECIAL CONDITIONS
This permit is hereby issued for the vegetative materials applied for but may be canceled if it appears that this permit was issued erroneously or the terms or conditions contained herein
are not observed. It will be subject to the following special conditions:
Conservation practices must be carried out as provided by 43 CFR 5511.1-1(b), 5511.2-3(c), and 5511.3-3.
Equipment, personal property, and improvements must be removed within ninety (90) days after the expiration date. 43 CFR 5511.3-5.
Any use of the surface of the lands involved in this permit must not interfere with any mining claim subject to the provisions of 30 U.S.C. 613.
The permittee must clean up all work areas and must remove or dispose of all refuse resulting from the permittee’s operations.
This permit is issued under 16 U.S.C. 604-607a; 16 U.S.C. 612; 16 U.S.C. 3111, 3112, and 3121 (Alaska National Interest Lands Conservation Act) ; and 43 CFR Part 5510 and 5511.
(Date)
(Signature of BLM)
APPLICANT FIELD OFFICE
The Paperwork Reduction Act of 1995 requires us to inform you that:
• The BLM collects this information to establish vegetative material, quantity, and compliance with the Free Use Regulations. Submission of the requested
information is necessary to complete the permit transaction and obtain or retain a benet.
• The BLM would like you to know that 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 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. Please send comments regarding the burden estimate or any
other aspect of this form to U.S. Department of the Interior, Bureau of Land Management (1004-0001), Bureau Information Collection Clearance Ofcer
(WO-630), 1849 C Street, NW, Room 2134, Washington, D.C. 20240.
(Form 5510-1)
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