Form 4710-10 Application for Adoption & Sale of Wild Horses or Burros

Save
Form 4710-10
(June 2018)

Print

Clear

UNITED STATES
DEPARTMENT OF THE INTERIOR
BUREAU OF LAND MANAGEMENT

APPLICATION FOR ADOPTION & SALE OF WILD HORSES OR BURROS

FORM APPROVED
OMB NO. 1004-0042
Expires: February 29, 2020

Instructions
1. Carefully read the PROHIBITED ACTS and TERMS OF
3. Submit your completed Application for Adoption & Sale of
ADOPTION printed on page 3.
Wild Horse(s) or Burro(s) to a Bureau of Land Management
2. Read the information provided in the WH&B “How-To-Guide”
(BLM) staff member or send to the office serving your State.
pamphlet.
(For correct address information, refer to the WH&B pamphlet
“How-To-Guide” or take it to an adoption event.).
Applicant Information (REQUIRED)
TODAY I AM:
Adopting:
Both:
Purchasing:
Complete section 2 & 3 only
Complete sections 1, 2 & 3
Complete section 1 only
How many animals are you requesting? (Provide quantity by age range): ___________ 1 to 4 Years Old __________ 5 & Older
How many of each species? Horses: __________ Female __________ Male
Burros: __________ Female __________ Male
Are you requesting a specific animal? Tag #: _____________ Tag #: _____________ Tag #: _____________ Tag #: _____________
Applicant Full Name:
Animal Group/Organization Name:
Personal Address/P.O. Box:
POC:
(P.O. Box Address requires physical address on page 2)
Tax ID/FEIN #:
City:
State:
Zip:
Address of housed animals:
Home/Cell Phone:
Alternate Phone:
City:
State:
Zip:
Primary Phone:
Email:
Email:
Section 1
Will you have someone else responsible for the care of the animals?
(If yes, include name, address, phone numbers, and e-mail address)

No

Yes:

Does your facility provide adequate feed and water?
No
Yes
(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. Facility may also be a pasture, however must be suitable for maintaining animals. Feed may be hay, grass or supplemental.
Water source may be natural, tank, pond or well)
Do you have a veterinarian available to provide care
for your wild horses and/or wild burros?
No
Yes:
(If yes, include name, address, phone numbers, and e-mail address)
When the Bureau of Land Management (BLM) sells a wild horse or burro, the animal is no longer considered a wild free-roaming
horse or burro under the Wild Free-Roaming Horses and Burros Act, 16 U.S.C. 1331 et seq. Purchased animals cannot be returned
to the public lands unless the BLM has issued a permit or otherwise authorized the purchaser to do so, such as through a livestock
grazing or recreational permit. By applying to purchase wild horses and/or burros, I understand the financial commitment to care for
such animals 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 purchase 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 I have read the above statement, understand the terms of this agreement, and agree to comply with them.
Purchaser’s Signature:
Date:
Congratulations on your new purchased Animal! Additional Questions? Contact BLM for more information.
Section 2
Driver’s Lic. or ID # and State Abbr.:

DOB:

MM/DD/YYYY

Social Security/TAX ID #:

Describe your existing facility, resources, and transportation:
(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:
Dimensions-Length:
Width:
Height of Corral:
Gate Height:
Gate Width:
Materials used in Corral
Materials used in Gate
(Continued on Page 2)

(Form 4710-10)

b) Shelter: (For minimum shelter requirements by state see page 4)
Type of Shelter:
Materials used in Shelter (If Applicable):
Length:
Width:
Included within corral sq. footage?:
Yes
No
Attached to Corral?
Yes
No
If not attached, how is it accessible?:
c) Feed:
Type of Hay or Pasture:
Supplemental Feed:
Amount per day:
d) Water:
Is there access to a water source?:
Yes
No
If yes, select your water source:
Well
City
Automatic Water
Other:
e) Trailer:
Type of trailer:
Stock
Horse
Homemade
Capacity (No. of animals):
Dividers?:*
Yes
No
If yes, can they be tied or folded back?
Yes
No
Number of rear doors:
1
2
Rear Doors:
Full Height
Half Height
Ramp:**
Yes
No
Is trailer covered?:
Yes
No
Does trailer have a solid top?
Yes
No
If not, describe the type of cover?:
* Some ages and species of animal are not normally loaded and/or hauled together and may require divisions within the trailer.
** Animals are not loaded into a trailer with a ramp, unless the ramp is a secondary door.
Have you ever been convicted of abuse or inhumane treatment of animals or found to be in violation of the Wild Free Roaming
Yes
No
Horse and Burro Act or the Wild Horse and Burro Regulations?
Have you previously adopted animals through the Wild Horse and Burro Program?
Yes
No
If your answer is yes, are these animals titled?
Yes
No
How many untitled animals do you have?
Will more than four untitled animals be at the location described on the application?
Have you ever adopted under a different last name?

Yes

No

Yes

No

If yes, what other name was used?

Section 3
Physical Address

City

Property Owner(s) Name

State

Zip Code

Property Owner(s) Phone Number
LOCATION OF ADOPTED ANIMALS

Draw a map of the location where adopted animal(s) will
be housed (from the nearest major highway) & provide
directions to your location using the lines below.
N

(Continued on Page 3)

Draw a layout of the corral(s) and shelter(s) & provide a brief
description using the lines below.
N

(Form 4710-10, Page 2)

(a)
(b)
(c)
(d)
(e)

PROHIBITED ACTS
Maliciously or negligently injuring or harassing a wild horse or (f) Branding a wild horse or burro;
burro;
(g) Removing or altering a freeze mark on a wild horse or burro;
Treating a wild horse or burro inhumanely;
(h) Violating an order, term, or condition established by the BLM
Removing or attempting to remove a wild horse or burro from
under this part;
the public lands without authorization from the BLM;
(i) Commercially exploiting a wild horse or burro;
Destroying a wild horse or burro without authorization from
Any person who commits a prohibited act is subject to a fine of
the BLM, except as an act of mercy
not more than $2,000 or imprisonment for not more than one
Selling or attempting to sell a wild horse or burro or its
year, or both, for each violation.
remains;

TERMS OF ADOPTION
The following terms apply to all wild horses and burros adopted
(h) Title will remain with the Federal Government for at least 1
year after the Private Maintenance and Care Agreement is
under the Private Maintenance and Care Agreement:
executed and until a Certificate of Title is issued by the BLM;
(a) Adopters are financially responsible for providing proper care;
(i) Adoption fees are non-refundable; and
(b) Adopters are responsible, as provided by State law, for any
(j) Adopters are entitled to a replacement, if, within 6 months of
personal injury, property damage, or death caused by animals
the adoption date, the animal dies or is required to be destroyed
in their care, for pursuing animals that escape or stray, and for
due to a condition that existed at the time of adoption and if
costs of recapture;
the adopter provides a veterinarian statement that certifies that
(c) Adopters must not transfer animals for more than 30 days to
reasonable care would not have corrected the condition. All
another location or to the care of another individual without the
replacements will be handled as a refund (completed within 2
prior approval of the BLM;
weeks of notification) or a voucher for a replacement animal.
(d) Adopters must make animals available for physical inspection
A voucher is non-refundable; has a shelf-life of six months;
within 7 days of receipt of a written request by the BLM;
can be applied to more than one animal; is non-transferable;
(e) Adopters must notify the BLM within 7 days of discovery of
has to be redeemed at the same type of event as the original
an animal’s death, theft or escape;
adoption; and does not give the adopter any kind of preferential
(f) Adopters must notify the BLM within 30 days of any change in
treatment. Additionally, the amount of the voucher has to be
the adopter’s address;
redeemed all at one time; non-used funds are forfeited; and
(g) Adopters must dispose of remains in accordance with
bids above the voucher amount are due in full at the time of the
applicable sanitation laws; and
adoption. This policy will only apply to replacement animals,
and not repossessions or reassignments.
Failure to comply with these terms may result in the cancellation of the agreement, repossession of the animals,
and disapproval of requests for adoption of additional animals. In addition, violation of any term of a
Private Maintenance and Care Agreement is a prohibited act.
I have read and understand the above TERMS OF THE ADOPTION and PROHIBITED ACTIONS.
(Applicant’s Signature)

(Date)

By applying to adopt wild horses or burros, I understand the financial commitment to care for such animals. 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.

I have read the above statement, understand the terms of this agreement and agree to comply with them.
(Applicant’s Signature)
Adoption applicant is approved for:
No. of Burros

(Date)
BLM USE ONLY
No. of Horses Younger than 18 mos.

No. of Trained Animals

No. of Horses Older than 18 mos.
Total No. of Animals Approved for Adopter’s Facility
Adoption applicant Disapproved (Disapproval will be accompanied by a decision letter to the applicant with appeal rights.)
(BLM Official’s Signature)

(BLM Official’s Printed Name)

(Office)

(Date)

**This application expires one year after the date of approval by the BLM Official’s Signature**
(Continued on Page 4)

(Form 4710-10, Page 3)

NOTICES
The Privacy Act and the regulation at 43 CFR 2.48 (d) require that
on public lands, i.e., the U.S. Forest Service (USFS) and the
you be furnished the following information in connection with
Animal and Plant Health Inspection Service (APHIS);
(6) Identify and assign level of system access required by BLM,
information required by this application.
USFS and APHIS wild horse and burros program personnel;
AUTHORITY: 16 U.S.C. 1333 and 31 U.S.C. 7701.
and
PRINCIPAL PURPOSE: The BLM will use this information to
(7) Authorize the disclosure of records to individuals involved in
process your agreement for private maintenance and care of wild
responding to a breach of Federal data.
horses or burros. BLM will use your driver’s license and social
EFFECT OF NOT PROVIDING INFORMATION: Submission
security numbers for debt collection purposes under the authority
of the requested information is necessary to obtain or retain a
of the Debt Collection Improvement Act, 31 U.S.C. 7701.
benefit. Failure to submit all of the requested information or to
ROUTINE USES: The primary uses of the information are to:
complete this form may result in the rejection and/or denial of your
(1) Identify individuals who have applied to obtain custody of a
application.
wild horse or burro through adoption or sale;
The Paperwork Reduction Act of 1995 (44 U.S.C. 3501 et seq.)
(2) Document the rejection, suspension, or granting of the request
requires us to inform you that:
for adoption or sale;
The BLM collects this information in accordance with the statutes
(3) Monitor compliance with laws/regulations concerning
and regulations listed above, and for the purposes listed above.
maintenance of adopted animals;
(4) Identify contractors/employees/volunteers/service providers
Submission of the requested information is necessary to obtain or
required to perform program functions;
retain a benefit. You do not have to respond to this or any other
(5) Provide necessary program management information to other
Federal agency-sponsored information collection unless it displays
agencies involved in management of wild horses and burros
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 effects of inclement weather and
temperature extremes. The requirement
is at the discretion of the authorized
officer 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 Officer,
(WO-630), 1849 C Street, N.W., Washington, D.C. 20240.
(Form 4710-10, Page 4)