Form 4710 10 PDF Details

The Form 4710-10, developed by the United States Department of the Interior and administrated by the Bureau of Land Management (BLM), serves as a critical instrument in the adoption process of wild horses and burros. As of March 2011, this form not only facilitates the application procedure but also encapsulates the BLM's commitment to the humane treatment and welfare of these animals. Intending adopters are required to provide detailed information ranging from personal identification to specifics about the facilities where the animals will be housed, underscoring the rigorous considerations involved in qualifying for adoption. Through questions that probe into an applicant's previous experiences with adopted animals, facility specifications, and even convictions related to animal abuse, the form comprehensively evaluates suitability for adopting these wild creatures. Moreover, terms of adoption outlined within the document ensure adopters are fully aware of their responsibilities, including care and legal obligations post-adoption, aiming to fortify the protection and preservation of wild horses and burros. The inclusion of prohibitions against acts such as inhumane treatment and unauthorized selling reiterates the legal and ethical framework governing the adoption process. This attentiveness to both the welfare of animals and the qualifications of prospective adopters reflects a nuanced approach to wildlife management and conservation efforts.

QuestionAnswer
Form NameForm 4710 10
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesadoption_applic ation_4710 010 icd 10 facility superbills form

Form Preview Example

Form 4710-10

UNITED STATES

 

 

(March 2011)

DEPARTMENT OF THE INTERIOR

 

FORM APPROVED

 

 

 

 

 

BUREAU OF LAND MANAGEMENT

 

OMB NO. 1004-0042

APPLICATION FOR ADOPTION OF WILD HORSE(S) OR BURRO(S)

 

Expires: March 31, 2014

 

 

 

 

 

 

 

 

 

 

 

 

Applicant’s Last Name

 

First Name

 

Middle Initial

 

 

 

 

 

Street Address or P.O. Box

 

City

State

Zip Code

(P.O. Box Address requires physical facility address on page 2)

 

 

Driver’s License Number

State

Birth Date

Social Security Number or Tax Identiication Number

 

 

 

 

 

 

 

 

 

 

 

Home Phone (Include area code)

 

Alternate Phone (Include area code)

 

 

E-Mail Address

 

 

 

 

 

 

 

 

 

 

 

 

Number of animals requested:

 

 

 

 

 

 

 

 

 

 

Burros

 

Horses (Younger than 18 mos.)

 

 

 

Horses (Older than 18 mos.)

 

Trained Animals

 

 

 

 

 

 

 

 

 

 

 

 

 

Question 1. Describe your existing facility and transportation:

a) Corral

Dimension: Length

 

 

 

 

 

 

 

Width

 

 

Height of Corral

 

Gate Height

 

 

 

 

 

 

 

Gate Width

 

 

 

 

 

 

 

 

Materials used in Corral

 

 

 

 

 

 

 

 

 

 

 

 

Materials used in Gate

 

 

 

 

 

b) Shelter

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Maximum Height

 

 

 

 

Minimum Height

 

 

 

 

Gate Height

 

 

 

 

Gate Width

 

Materials used in Shelter

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No; If not attached, how is it accessible?

 

 

 

 

 

 

 

 

 

 

Attached to Corral?

 

 

Yes

 

 

 

 

 

 

 

 

 

 

 

c) Feed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Type of Hay or Pasture

 

 

 

 

 

 

 

 

 

 

 

Amount per Day

 

 

 

 

 

 

 

Supplemental Feed

d) Water

Tank Capacity (gallons)

Other: Describe

 

Automatic Water

Source of Water:

 

 

 

 

 

 

 

Well

City

e) Trailer:

Brand Name/Manufacture Year (if known)

 

 

 

 

 

 

 

 

 

Capacity (No. of animals)

 

Type:

 

Stock

 

 

Horse

 

 

Other--describe

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Number of rear doors:

 

 

2

Ramp:**

 

Yes

 

No

Rear Doors:

 

Full Height

 

Half Height

 

 

1

 

 

 

 

 

Home-made--describe

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*Some ages and species of animal are not normally loaded and/or hauled together and may require divisions within the trailer. ** Animals are not normally loaded into a trailer with a ramp.

Question 2. 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?

Question 3. Will more than four untitled animals be kept at the location described? Yes No

Question 4. Have you ever adopted under another last name? Yes No If yes, what other name did you use?

Question 5. Have you ever been convicted of abuse or inhumane treatment of animals, violation of the Wild Free Roaming Horse

and Burro Act or the Wild Horse and Burro Regulations?

 

Yes

 

No

 

 

 

 

 

(Continued on page 2)

Applicant’s Name

MAP OF LOCATION OFADOPTED WILD HORSES AND/OR BURROS

Facility Address

City

State

Zip Code

Property Owner(s) Name

Phone Number

Draw a map to the location where animal(s) will be kept (from the

Draw a layout of corral(s) and shelter(s).

nearest major highway).

 

N

N

 

 

Directions to the Facility

INSTRUCTIONS

1.Carefully read the PROHIBITED ACTS and TERMS OF ADOPTION printed below.

2.Carefully read information provided in the pamphlet “Adopting a Wild Horse or Burro.”

3.Submit your completed Application for Adoption of Wild Horse(s) or

Burro(s) to the Bureau of Land Management (BLM) ofice serving your

State. (For the correct address, refer to the pamphlet “Adopting a Wild Horse or Burro” or take it to an adoption event.)

4.So that we may notify you when and where the animal(s) you

requested are available, provide the Bureau of Land Management ofice serving your State within 10 days of any change in your address or telephone number.

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 subｍect to a ine of not more

than $2,000 or imprisonment for not more than one year, or both, for each violation.

(Continued on page 3)

(Form 4710-10, page 2)

Applicant’s Name

TERMS OF ADOPTION

The following terms apply to all wild horses and burros adopted under this Private Maintenance and Care Agreement:

(a)Adopters are inancially 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 adopter’s address;

(g)Adopters must dispose of remains in accordance with applicable sanitation laws; and

(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 Certiicate of Title is issued by the BLM.

(i)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 certiies that reasonable care would not have corrected the condition. All replacements will be handled as a refund (completed within 2 weeks of notiication) or a voucher for a replacement animal. A voucher is non-refundable; has a shelf-life of six months; can be 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 one time; 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.

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)

 

 

 

 

 

 

 

 

 

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 state that I have no intent to sell this wild horse or burro for slaughter or bucking stock, or for processing into commercial products, within the meaning of the Wild and Free Roaming Horse and Burro Act, 16 U.S.C. 1331 et seq., and regulations 43 CFR 4700.0-5(c). I have read the above statement, understand the terms of this agreement and agree to comply with them.

 

(Applicant’s Signature)

 

 

 

(Date)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Approved for:

 

No. of Burros

 

 

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

Disapproved (Disapproval will be accompanied by a decision letter to the applicant with appeal rights.)

(BLM Oficial’s Signature)

 

(BLM Oficial’s Printed Name)

 

(Ofice)

 

(Date)

This application expires one year after the date of approval by the BLM Oficial’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 you be furnished the following information in connection with information required by this application.

(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 (FS) and the Animal and Plant Health Inspection Service (APHIS);

AUTHORITY: 16 U.S.C. 1333 and 31 U.S.C. 7701.

PRINCIPAL PURPOSE: The BLM will use this information to process your agreement for private maintenance and care of wild horses or burros. BLM will use your driver’s 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;

(6)Identify and assign level of system access required by BLM, FS 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 beneit. 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 beneit. 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

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 Oficer, (WO-630), 1849 C

Street, N.W., Washington, D.C. 20240.

(Form 4710-10, page 4)

How to Edit Form 4710 10 Online for Free

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Step 1: Open the PDF in our editor by clicking on the "Get Form Button" above on this webpage.

Step 2: As you open the file editor, you will see the document prepared to be filled out. In addition to filling in different blank fields, you may as well do other things with the Document, such as writing any text, editing the initial text, inserting images, putting your signature on the PDF, and a lot more.

This form will require specific info to be filled in, so be certain to take some time to provide exactly what is required:

1. Start filling out the Form 4710 10 with a number of major blanks. Collect all of the important information and ensure nothing is forgotten!

Filling out part 1 of Form 4710 10

2. Once your current task is complete, take the next step – fill out all of these fields - Attached to Corral, Yes, No If not attached how is it, c Feed, Type of Hay or Pasture, Supplemental Feed, d Water, Tank Capacity gallons, Other Describe, e Trailer, Amount per Day, Automatic Water, Source of Water, Well, and City with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Filling in part 2 of Form 4710 10

3. The following section is mostly about Question Have you ever adopted, Yes, No If yes what other name did you, Question Have you ever been, and Burro Act or the Wild Horse, Yes, and Continued on page - type in each of these blanks.

Continued on page, Yes, and Question Have you ever been inside Form 4710 10

4. All set to complete this next section! In this case you have all of these Applicants Name, Facility Address, City, Property Owners Name, MAP OF LOCATION OF ADOPTED WILD, State, Zip Code, Phone Number, Draw a map to the location where, and Draw a layout of corrals and blank fields to do.

Stage no. 4 in filling in Form 4710 10

Those who work with this PDF frequently make mistakes when filling out City in this area. Remember to read again whatever you enter here.

5. The very last section to finish this PDF form is crucial. Make sure that you fill out the mandatory blanks, for instance Directions to the Facility, Carefully read, the PROHIBITED ACTS and TERMS OF, State For the correct address, ADOPTION printed below, Carefully read information, Horse or Burro, Submit your completed Application, Horse or Burro or take it to an, So that we may notify you when, INSTRUCTIONS, PROHIBITED ACTS, a Maliciously or negligently, c Removing or attempting to remove, and public lands without authorization, prior to finalizing. Otherwise, it may contribute to an unfinished and probably nonvalid paper!

Form 4710 10 writing process shown (part 5)

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