FS-2400-1
BLM-5450-24
(08/2016)
OMB No.: 0596-0085
Expires: 10/31/2018
FOREST PRODUCTS REMOVAL PERMIT and CASH RECEIPT
(Auth: 16 USC 472a, 551; 30 USC 601, 602; 43 USC 1201; 16 CFR 223; & 43 CFR 5420)
U.S. DEPARTMENT OF AGRICULTURE – FOREST SERVICE
U.S. DEPARTMENT OF THE INTERIOR – BUREAU OF LAND MANAGEMENT
FS Region/BLM State: [ ]
FS National Forest/BLM District: FS Ranger District/BLM Field Ofce:
Permittee’s Name and Complete Address: Permit No.
Preparation Date Payment Method
Name:
Address:
Effective Date Termination Date Load Ticket Numbers
From: Thru:
City/State:
Product Plan
From: Thru:
Zip Code: Number:
Name:
Permittee Identication
Type
Public Land Type
County
Vehicle(s) Information Associated Charges Permit Area Description:
Year: Year:
Fund Amount
Make: Make:
Model: Model:
Color: Color:
License: License:
State: State:
Remarks:
PRODUCT DESIGNATION
Product Species
Unit of
Measure
(UOM)
Quantity
Sold
Rate Per
Product
UOM
Assoc.
Charges
$ per UOM
Total Cost of
Products
($)
Cost of
Assoc. Charges
($)
Total Permit Costs:
Total Purchase Price:
PRODUCT QUANTITY REMOVAL RECORD
Date Time
Quantity
Removed Date Time
Quantity
Removed Date Time
Quantity
Removed Date Time
Quantity
Removed
For BLM lands only, Permittee certies that they are of the age of majority in the state they reside in and, if purchasing timber, are a United States citizen
SIGNATURES
PERMITTEE Date AUTHORIZED AGENCY/VENDOR Date
PRIVACY ACT NOTICE
The following information is provided to comply with the Privacy Act of 1974 (PL-579). 5 U.S.C. 552a authorizes acceptance of the information requested on this form. The Forest
Service and Bureau of Land Management use this information to maintain an inventory of forest product information and to adjudicate your rights to forest products. The information
required by this form may be disclosed pursuant to the regulations in 7 CFR 1.5 or 43 CFR 2.56. If you do not furnish all the information required by this form, your application may be
rejected.
BURDEN AND NONDISCRIMINATION STATEMENTS
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a
valid OMB control number. The valid OMB control number for this information collection is 0596-0085. The time required to complete this information collection is estimated to average
5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the
collection of information. The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, age, disability,
and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because all or part of an individual’s
income is derived from any public assistance. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program
information (Braille, large print, audiotape, etc.) should contact USDA’s TARGET Center at 202-720-2600 (voice and TDD). To le a complaint of discrimination, write USDA, Director, Ofce
of Civil Rights, 1400 Independence Avenue, SW, Washington, DC 20250-9410 or call toll free (866) 632-9992 (voice). TDD users can contact USDA through local relay or the Federal relay
at (800) 877-8339 (TDD) or (866) 377-8642 (relay voice). USDA is an equal opportunity provider and employer.
(Continued on page 2)
(Form 5450-24, page 1)
