OSM-1 Coal Reclamation Fee Report

U.S. Department of the Interior, Office of Surface Mining Reclamation and Enforcement
Part 1 -- OSM-1

2.

Coal Reclamation Fee Report
1.

Reporting for ‫ ܆‬1st, ‫ ܆‬2nd, ‫ ܆‬3rd, or ‫ ܆‬4th quarter, 20____.

______________________________________________________________________
Print in ink or type the name of reporting person, corporate officer, agent or director
on behalf of the operator or the permittee signing below.

This certification covers the following permit number(s):
State

I hereby certify that the statements made herein are true, complete and
correct to the best of my knowledge and belief and are made in good
faith

Permit Number

______________________________________________________________________
Signature
Date

3.

Contact name:
Telephone:
Email:
Entity:

4.

Amount Due: $_______________._____
Credits or Amounts
due from previous filings $_______________._____
Total Due: $_______________._____
Total Payment: $_______________._____
Check one: ‫ ܆‬Electronic funds transfer

5.

- Submit a properly notarized copy of the OSM-1 form-

Subscribed and sworn to before me in my presence the
of __________, 20______.

- Sign an unsworn statement-

______ day

______________________________________
Commission expires:_______
Notary Public signature

‫ ܆‬Check

OR

“I declare under penalty of perjury that the foregoing is true and
correct. Executed on _____ day of ________, 20_____.”
__________________________________________________
Signature

Title 30 U.S.C. Section 1232 provides that any person, corporate officer, agent or director, on behalf of a coal mine operator who knowingly makes any false statements, representation or certification, or
knowingly fails to make any statement, representation or certification required in this section shall, upon conviction, be punished by a fine of not more than $10,000, or by imprisonment for not more than one
year or both. Approved by OMB, no.1029-0063. Expires 2/29/2024 Call 1-800-799-4265 if you have any questions

Part 2 -- OSM-1 Coal Reclamation Fee Report, OSM-1
File Typeapplication/pdfFile TitleOSM1MainAuthorSalomon, Michael ThomasFile Modified2021-02-01File Created2020-11-10