Amendment to Collateral Bond and Indemnity Agreement (Co

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

AMENDMENT TO COLLATERAL BOND AND INDEMNITY AGREEMENT
(Corporation)
To be attached to and form a part of the Collateral Bond and Indemnity Agreement
executed by ______________________________________________________ AS OBLIGOR,
(Corporation – Permittee)

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 _______________________________.
Whereas, OSM issued Permit No._____________ and dated on _______________, and Permit
Renewals and Revisions numbered and dated: _______________________________
______________________________________________________________________________
pursuant to the application of the Obligor;
WHEREAS, said collateral bond and indemnity agreement and amendment 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 amendment is:

It is further agreed that all other terms and conditions of this collateral bond and
indemnity agreement shall remain unchanged.

IN WITNESS WHEREOF, the Obligor has hereunto set its signature and seal this
day of ___________________,
.
________________________________

By: ________________________________
(Corporate Officer1)

(Corporation/Permittee)

_____________________________
(Title)
1
Where one signs by virtue of Power of Attorney or Corporate Resolution for a corporate Principal, a certified copy of the Power
of Attorney or Corporate Resolution must be filed with the collateral bond.

Permit No. _________________

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Collateral Amendment - Corporate

ACKNOWLEDGEMENT OF CORPORATION - OBLIGOR
On this _____ day of __________________________,
, before me, a Notary
Public in and for the County of _____________________ , in the State of _____
,
appeared _________________________ to me personally known who, being by me fully sworn,
, the corporation named in and
did say that he/she is of
which executed the within instrument, and that the seal affixed to said instrument is the corporate
seal of said corporation, and that said instrument was signed, sealed and delivered on behalf of
said corporation by authority of its Board of Directors, and he/she, as such officer, acknowledged
said instrument to be the free act and deed of said corporation for the uses and purposes of said
instrument as therein set forth.
IN WITNESS WHEREOF, I have hereunto set my hand and official seal on the day,
month, and year aforesaid.
My Commission Expires: ____________________________________
________________________________________
Notary Public in aforesaid County and State

NOTE: Where negotiable securities are used as collateral, a completed POWER of ATTORNEY
AND AGREEMENT must be attached.

Paperwork Reduction Act Notice
We use the information required by this form to ensure that the requirements for a collateral bond under 30 CFR
800.21 are met. You must provide the requested information to obtain or retain a benefit (a collateral 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 2 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 9/30/2015

Permit No. _________________

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Collateral Amendment - Corporate