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LIVESTOCK LOSS BOARD

PO BOX 202005

HELENA, MONTANA 59620-2001

<div style="text-align: center;"><img src="imgs/img_in_image_box_1153_329_1459_442.jpg" alt="Image" width="12%" /></div>


BOARD OFFICE: (406) 444-5609

WEBSITE: www.llb.mt.gov

EMAIL: LIVLossBoard@mt.gov

## LOSS PREVENTION GRANT APPLICATION SUPPLEMENT

Livestock loss prevention projects conducted by an organization working on behalf of livestock producers require a representative from each ranch indicating their participation in the project.


<table border=1 style='margin: auto; word-wrap: break-word;'><tr><td colspan="3">Livestock Owner or Ranch Name</td><td style='text-align: center; word-wrap: break-word;'>Primary Contact (if different)</td></tr><tr><td colspan="3">Address</td><td rowspan="2">Phone</td></tr><tr><td style='text-align: center; word-wrap: break-word;'>City</td><td style='text-align: center; word-wrap: break-word;'>State</td><td style='text-align: center; word-wrap: break-word;'>Zip</td></tr></table>

## LIVESTOCK INFORMATION:

Please list the number and type of animals that will be protected by this project:


<table border=1 style='margin: auto; word-wrap: break-word;'><tr><td style='text-align: center; word-wrap: break-word;'>Species</td><td style='text-align: center; word-wrap: break-word;'>Number</td><td style='text-align: center; word-wrap: break-word;'>Description (breed, age, sex, commercial vs registered, etc.)</td></tr><tr><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td></tr><tr><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td></tr><tr><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td></tr><tr><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td></tr><tr><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td></tr></table>

I attest that I am a livestock owner or ranch manager participating in a livestock loss prevention project conducted by ___

(Name of Organization)

Signature: ___

Date: _____

When providing information to the board for qualification under this section, applicants are subject to the false swearing penalties established in 45-7-202. Any person who knowingly and willfully gives false information for the purpose of prevention grants as provided in this section is guilty of a misdemeanor, punishable by a fine not to exceed $5,000 or imprisonment in the county jail for a term not to exceed 1 year, or both.