Amended OSM-1 Amended OSM-1 Coal Reclamation Fee Report

U.S. Department of the Interior, Office of Surface Mining Reclamation and Enforcement

Amended OSM-1 Coal Reclamation Fee Report
2.

Use this form to change an OSM-1 report already submitted. Send this form with any supporting
documentation along with a check or wire transfer for applicable fees to: Office of Surface Mining
Reclamation and Enforcement, P.O. Box 979068, St. Louis, MO 63197-9000

Entity Number ____________________________________
Permit __________________________________________

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

1.

MSHA Number ___________________________________
Mine Name ______________________________________

______________________________________________________________________
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.

State ___________________________________________
Contact Name ____________________________________

_____________________________________________________________________
Signature
Date

3.

Block A
Enter originally reported tonnage below:

a. Gross Tons

.

b. Moisture
(1) Total
(2) Inherent
(3) Excess

.
.
.

Telephone Number ________________________________

Block B

Block C

Enter amended tonnage below:

a. Gross Tons
%
%
%

Enter the difference between A and B below:

.

b. Moisture
(1) Total
(2) Inherent
(3) Excess

.
.
.

.

c. Reduced Tons

.

d. Net Tons

.

d. Net Tons

.

$.

f. Calculated Fee $

e. Rate
.

$.

f. Calculated Fee $

Enter the difference between A and B :

%
%
%

c. Reduced Tons

e. Rate

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

.

… + plus
… - minus
Calculated Fee:
$

.

check
wire transfer

Please explain the changes to your original filing on the back of this form

4.

- Sign an unsworn statement-

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

Subscribed and sworn to before me in my presence the
______ day of __________, 20______.
______________________________________
Commission expires:_______
Notary Public signature
Approved by OMB, no. 1029-0063. Expires 2/29/2024

OR

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

Paperwork Reduction Act Statement
This information is being collected to comply with the regulatory requirements of 30 CFR 870.15(b) which requires each operator to use mine report OSM-1 form and this
Amended OSM-1 form as needed to report the coal tonnage sold, used or ownership transferred during the applicable calendar quarter. Response to this request is mandatory
in accordance with Section 402(a) of the Surface Mining Control and Reclamation Act of 1977, 30 USC 1232.
Burden Estimate
Public reporting burden for the Amended OSM-1 form based on one permit is 5 minutes to complete the electronic form and 15 minutes to complete the paper form. The
burden estimates include the time for reviewing instructions, searching existing data sources, gathering and maintaining the date needed, and completing and reviewing the
form. Submit comments regarding this burden estimate or other aspects of this form to: Information Collection Clearance Officer, Office of Surface Mining Reclamation
and Enforcement. Approved by OMB, no. 1029-0063. Expires 2/29/2024