General Purpose Rider for Surety Bond

United States Department of the Interior
Office of Surface Mining Reclamation and Enforcement
GENERAL PURPOSE RIDER FOR SURETY BOND
Permit No. _____________

Bond No.___________

To be attached to and form a part of Surety Company Bond No.______________ written
by _____________________________________________________ AS SURETY, on behalf of
___________________________________________________________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, ___________________, 20_____.
Whereas, OSM issued Permit No._________________, dated on__________________
and Permit Renewals and Revisions numbered and dated: ____________________________
___________________________________________________________________________
pursuant to the application of the Principal;
Whereas, said 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 bond shall remain
unchanged. This rider shall be effective this _____ day of _____________, 20__.

PRINCIPAL
Signed and executed this _______ day of _______________________, 20____.
BY:_____________________________________

(Affix Seal)

TITLE:__________________________________
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:_____________________

SURETY
Signed and executed this ______ day of ______________________, 20_____.
BY:_________________________________________

(Affix Seal)

TITLE:
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:______________________

Permit No._____________

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Surety Bond General Rider

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 officer)

My Commission Expires: _____________________

Paperwork Reduction Act Notice
We use the information required by this form to ensure that the requirements in 30 CFR Part 800.20 continue to be
met as conditions change. You must provide the requested information to obtain a benefit (continuation of a surety
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 one hour 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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Surety Bond General Rider