Form 3830-002 Form 3830-002 Maintenance Fee Waiver Certification

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Form 3830-2

(January 2017)

UNITED STATES DEPARTMENT OF THE INTERIOR BUREAU OF LAND MANAGEMENT

MAINTENANCE FEE WAIVER CERTIFICATION

SEE INSTRUCTIONS ON PAGE 2

FORM APPROVED OMB NO. 1004-0114

Expires: January 31, 2020

1. This small miner waiver is filed for the assessment year beginning on September 1, and ending on September 1, .

2. The undersigned and all related parties owned ten or fewer mining claims , mill, or tunnel sites located and maintained on Federal lands in the United States of America on September 1, .

3. The undersigned have performed the assessment work required by law for each mining claim listed prior to filing this waiver and understand that by filing this form, the undersigned must file an affidavit of assessment work with the Bureau of Land Management (BLM) by the December 30th following the filing of this waiver.

4. The undersigned understand that if the assessment work obligation has not yet come due under 30 U.S.C. 28 (for those claims in their first assessment year only), a notice of intent to hold reciting this condition must be recorded by the December 30th following the filing of this waiver.

5. The undersigned understand that mill and tunnel sites may also be listed on this waiver and be waived from payment of the maintenance fee, and that a notice of intent to hold for these sites is required to be filed with the BLM by the December 30th following the filing of this waiver.

6. The undersigned understand and acknowledge that pursuant to 43 U.S.C. 1212 and 18 U.S.C. 1001, the filing or recording of a false, fictitious, or fraudulent document with the BLM may result in a fine of up to $250,000, a prison term not to exceed five years, or both.

7. The mining claims, mill or tunnel sites for which this waiver from payment of the maintenance fees is requested are:

The owner(s) (claimants) of the above mining claims and sites are:

(Owner’s Name - Please Print) (Owner’s Signature)

(Owner’s Mailing Address) (City) (State) (Zip Code)

(Owner’s Name - Please Print) (Owner’s Signature)

(Owner’s Mailing Address) (City) (State) (Zip Code)

(Owner’s Name - Please Print) (Owner’s Signature)

(Owner’s Mailing Address) (City) (State) (Zip Code)

(Owner’s Name - Please Print) (Owner’s Signature)

(Owner’s Mailing Address) (City) (State) (Zip Code)

(Continued on page 2)

(Owner’s Name - Please Print) (Owner’s Signature)

(Owner’s Mailing Address) (City) (State) (Zip Code)

(Owner’s Name - Please Print) (Owner’s Signature)

(Owner’s Mailing Address) (City) (State) (Zip Code)

(Owner’s Name - Please Print) (Owner’s Signature)

(Owner’s Mailing Address) (City) (State) (Zip Code)

(Owner’s Name - Please Print) (Owner’s Signature)

(Owner’s Mailing Address) (City) (State) (Zip Code)

18 U.S.C. 1001 and 43 U.S.C. 1212 make it a crime for any person knowingly and willfully to make to any department or agency of the United States any

false, fictitious or fraudulent statements or representations as to any matter within its jurisdiction.

INSTRUCTIONS

1. This certification is made under the provisions of 43 U.S.C. § 1744 and 30 U.S.C. §28-28k and the regulations thereunder (43 CFR Part 3830).

2. The claimant(s) must fill in the dates in paragraph 1 for the beginning and ending of the assessment year for which this waiver is sought.

3. The claimant(s) must fill in the date in paragraph 2 for the beginning of the assessment year for which this waiver is sought.

4. All claim and site names and BLM serial numbers must be listed for the mining claims, mill sites, and tunnel sites for which the waiver is sought.

5. All owners of the mining claims, mill sites, and tunnel sites and their addresses must be given.

6. This waiver form must be signed by all the claimants or their designated agent, in original form. If an agent is designated, a notarized designation of agent, signed by all of the claimants with proper address given, must be submitted with this waiver.

7. This form must be filed no later than September 1st for the upcoming assessment year in the BLM State Office where the mining claims or sites are recorded, or the waiver cannot be granted by the BLM. (Example: To obtain a waiver for the assessment year 2012, which begins on September 1, 2011, you must qualify for and file for a waiver no later than September 1, 2011, in the proper BLM State Office.)

8. For all mining claims which require assessment work, you must record an affidavit of labor on or before the December 30th immediately following the filing of this waiver. For all other mining claims or sites waived, you must record a notice of intent to hold on or before the December 30th immediately following the filing of this waiver.

9. Mill and tunnel sites may also be listed on this waiver and be waived from payment of the maintenance fee. A notice of intent to hold for these sites is required to be filed by the December 30th following the filing of this waiver.

(Continued on page 3) (Form 3830-2, page 2)

NOTICES

The Privacy Act and 43 CFR 2.223(d) require that you be furnished the following information in connection with the information requested by this form.

AUTHORITY: 30 U.S.C. 28f and 43 CFR part 3835 permit collection of the information requested by this form.

PRINCIPAL PURPOSE: The BLM will use the information you provide to verify that the owner(s) (claimants(s)) of a mining claim

has/have complied with 30 U.S.C. 28f and 43 CFR part 3835 and is/are entitled to perform assessment work in lieu of paying the maintenance fee for the mining claims listed on this form.

ROUTINE USES: The BLM will only disclose this information in accordance with the provisions at 43 CFR 2.231(b) and (c). EFFECT OF NOT PROVIDING INFORMATION: Disclosure of the requested information is required by 30 U.S.C. 28f and

43 CFR part 3835 for those claimants qualified to request the small miner waiver allowed. Failure to submit all the requested information or to complete this form will delay the BLM’s processing of the form and may preclude the BLM’s acceptance of the maintenance

fee waiver request, which may result in forfeiture of the mining claim or site by the claimant.

RELEVANT SYSTEM OF RECORDS NOTICE (SORN) CITATION: The Recordation of Mining Claims SORN may be found at 47 FR 55326 (December 8, 1982).

The Paperwork Reduction Act requires us to inform you that:

The BLM collects this information to determine whether or not you are qualified for waiver of maintenance fees. Submission of the requested information is necessary to obtain or retain a benefit.

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 20 minutes per response, including the time for reviewing instructions, gathering and maintaining data, and completing and reviewing the form. You may submit comments regarding the burden estimate or any other aspect of this form to: U.S. Department of the Interior, Bureau of Land Management

(1004-0114), Bureau Information Collection Clearance Officer (WO-630), Mail Stop 401 LS, 1849 C St., N.W., Washington, D.C. 20240.

(Form 3830-2, page 3)