General purpose ri General purpose rider for self-bond

United States Department of the Interior
OFFICE OF SURFACE MINING RECLAMATION AND ENFORCEMENT

GENERAL PURPOSE RIDER FOR SELF-BOND

Permit No._________________

Self-Bond No._______________

To be attached to and form a part of Self-Bond No._______________________________
executed by _____________________________________________________, AS PRINCIPAL,
in the sum of __________________________________________________________________
____________________________________________________________________ DOLLARS
($____________________), in favor of the United States, Department of the Interior, Office of
Surface Mining Reclamation and Enforcement (OSM) and executed on ______ day
____________________, _______.
Whereas, the OSM issued Permit No. ___________________ and dated on
______________________________________, and Permit Renewals and Revisions numbered
and dated: ____________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
pursuant to the application of the Principal;
Whereas, said Self-Bond and rider shall cover any and all land affected or to be affected
by the mining operation under the above mentioned permit and revisions and renewals since the
date of the issuance of the permit;
Now, therefore, the purpose of this rider is:

It is further understood and agreed that all other terms and conditions of this self-bond shall
remain unchanged.

PRINCIPAL
Signed and executed this ________ day of ________________________, _______.
BY: ___________________________________
TITLE1: _______________________________

(Affix Seal)

State of _________________________)
) SS.
County of _______________________)

ACKNOWLEDGEMENT
The foregoing instrument was acknowledged before me by _____________________________
this ______ day of _________________________, 20_____.
Witness my hand and official seal ________________________________________________
(Notary Public or other authorized officer)

My Commission Expires: __________________________

RESIDENT AGENT FOR SERVICE
Resident Agent: _____________________________________Date:_______________________
(Signature)

___________________________________
(Printed Name)

_______________________________________________________________________
(Address)

ACKNOWLEDGEMENT
The foregoing instrument was acknowledged before me by _____________________________
this _______ day of __________________________,20_____.
Witness my hand and official seal.

______________________________________
(Notary Public or other authorized official)

My Commission Expires: ________________________
1

Where one signs by virtue of Power of Attorney or Corporate Resolution for corporate Principal, a certified copy of
the Power of Attorney or Corporate Resolution must be filed with this rider.

Permit No.____________

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Self-Bond General Purpose Rider

Paperwork Reduction Act Notice
We use the information required by this form to ensure that the requirements for self-bonds under 30 CFR 800.23
are met. You must provide the requested information to obtain or retain a benefit (a self-bond). Under 30 CFR
842.16, the information collected is a matter of public record.
The time needed to complete this form and submit the requested information will vary depending on individual
circumstances. We estimate that the average time will be 3 hours per response. This number includes the time spent
reviewing instructions, learning about the regulations, gathering and maintaining information, and completing and
reviewing the form. If you have comments concerning the accuracy of this estimate or suggestions for simplifying
the form or instructions, you may write to the Information Collection Clearance Officer, Office of Surface Mining
Reclamation and Enforcement, Room 202 SIB, 1951 Constitution Ave, NW, Washington, D.C. 20240.
Under the Paperwork Reduction Act of 1995 (44 U.S.C. 3501 et seq.), you are not required to respond to, nor will
you be subject to a penalty for a failure to comply with, a collection of information unless it displays a currently
valid OMB control number.
OMB Control No. 1029-0043; expires 1/31/2009

Permit No.____________

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Self-Bond General Purpose Rider