Application for Self-Bond

United States Department of the Interior
OFFICE OF SURFACE MINING RECLAMATION AND ENFORCEMENT
APPLICATION FOR SELF-BOND
Attach additional page(s) as needed and reference the application form item number to which addition(s)
apply. Financial data must be in U.S. Currency. NOTE: if the Parent Company of the Permittee is
applying for Self-Bonding as a corporate Guarantor, the Guarantor must respond to all items on the
application as the Applicant. If a non-parent corporation is applying as Guarantor under this application,
the Guarantor must address all items on the application form and the Permittee must also complete an
additional application to address all items except Item 7.
1. Identification of Permittee: _______________________________________ Permit No. _________
2. Identification of Applicant/Guarantor and Guarantor’s relationship to Permittee: _____________
________________________________________________________________________________
3. Type of Entity Applying for Self-bonding or Applying as Guarantor: ________________________
(i.e., Corporation, LLC, Joint Venture, Limited Partnership, Partnership, etc.)
(a) Corporations:
Address: _________________________________________________
Telephone No.: ____________________________________________
State of Incorporation: ______________________________________
Principal Place of Business: __________________________________
Name, Title and Authority of person signing this application: ____________________
_____________________________________________________________________
Certification of Authority to do business in (State where operation located):_________
_____________________________________________________________________
(b) OTHER forms of business enterprises:
Address: ________________________________________________________
Telephone: ______________________________________________________
State of Formation: ________________________________________________
Principal Place of Business: _________________________________________
Name, Title and Authority of person signing this application: ______________________
_______________________________________________________________________
4.

(a)

Amount of Bond required in accordance with 30 CFR §800.14: $____________________
_______________________________________________________________________

(b)

**

Amount which is proposed to be under a self-bond: _____________________________
________________________________________________________________________.

Permit No.____________

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Self Bond Application

(c)

Amount of this proposed self-bond plus all of your other outstanding, proposed, and
guaranteed self-bonds for coal mining operations in the United States: $__________
____________________________________________________________________

(d)

Tangible Net Worth in the United States: $__________________________________

5. A brief description and chronological history of those business operations of the applicant conducted
within the last five (5) years that would demonstrate a continuous operation. If the applicant is a joint
venture with less than five (5) years, describe the chronological history and business operations of the
individual joint ventures. List any past periods of interruption of the business operation and the reasons
for such interruption.

6. Attach audited financial statements in conformance with U.S. Generally Accepted Accounting
Principles (GAAP) to include:
(a) Applicant’s Balance Sheet for the most recently completed fiscal year.
(b) Applicant’s Income Statement for the most recently completed fiscal year.
(c) A report for the most recently completed fiscal year containing the audit or review opinion
of the audited financial statements with no adverse opinion by an independent certified public
accountant.
(d) Un-audited financial statements for all completed quarters in the current fiscal year.
7. Indicate under which of the three criteria at 30 CFR §800.23(b)(3) the applicant is applying to qualify
for self-bonding:
30 CFR §800.23(b)(3)(i)___________________________________________________________; or
30 CFR §800.23(b)(3)(ii)___________________________________________________________; or
30 CFR §800.23(b)(3)(iii)___________________________________________________________.
(i) If applying on the basis of the financial test at 30 CFR§ 800.23(b)(3)(i), provide the following
information:
a. Current bond rating of the most recent bond issuance of the applicant:________________
b. Name of rating service: _____________________________________________________
(Attach the bond rating service’s written confirmation of current bond rating.)
c. Date of issuance of the bond: ________________________________________________
d. Date of maturity of the bond: ________________________________________________
(ii) If applying on the basis of the financial test at 30 CFR §800.23(b)(3)(ii), provide the following
information:
a. Tangible net worth: $_____________________________________________________
b. Ratio of Current Assets to Current Liabilities: _________________________________
c. Ratio of Total Liabilities to Net Worth: _______________________________________
Permit No.____________

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Self Bond Application

(iii) If applying on the basis of the financial test at 30 CFR §800.23(b)(3)(iii), provide the following
information:
a. Fixed Assets in the United States (excluding land and coal in place):$_______________
b. Ratio of Current Assets to Current Liabilities: __________________________________
c. Ratio of Total Liabilities to Net Worth: ________________________________________
8. Registered agent for service of process (in the State where the permittee’s operation is located):
Name+:_____________________________________________________________________
Address: ____________________________________________________________________
Telephone Number:____________________________________________________________
OSM will notify the permittee in writing of its determination as to whether the applicant qualifies for selfbonding and whether OSM approves the self-bond. If approved for self-bonding, OSM will assign a SelfBond Number. Using this assigned number, several self-bonding documents must be executed by the
permittee and/or the Guarantor and approved by OSM. These documents include a Self-Bond Agreement
(Permittee); an Indemnity Agreement (Permittee and Guarantor) and a Corporate Guarantee (parent
Guarantor) or Non-Parent Corporate Guarantee, as applicable.
Provide the names and addresses of individuals who are to receive notice and the above forms from OSM:
For the Permittee: ____________________________________________________________________
For the Guarantor: ____________________________________________________________________
NOTES:
**
+

This plus all other outstanding and proposed self-bonds may not exceed 25% of an applicant’s tangible net
worth in the United States.
Any change in the registered agent must be filed immediately with OSM.

State of ________________________)
) SS
County of ______________________)
I_________________________________(please print or type) am the applicant for the foregoing application
to self-bond; I have read the application and fully know the contents thereof; and all statements contained
in the application to self-bond are true and correct to my best knowledge and belief.
Dated and signed this __________ day of __________________________, ______.
BY: _____________________________
(Corporate Seal)

TITLE: ___________________________
(please print or type)

State of ________________________)
) SS
County of ______________________)
Permit No.____________

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Self Bond Application

The foregoing instrument was acknowledged before me by ____________________________________
this _____ day of ____________________, ______.
(Name of Principal Signatory - please print or type)

Witness my hand and official seal.

____________________________________
(Notary Public or other Authorized Officer)

____________________________________
(Title)

(Name printed or typed)

My Commission Expires: ________________

Paperwork Reduction Act Notice
We use the information required by this form to determine whether a person qualifies for a self-bond under 30 CFR 800.23.
You must provide the requested information to obtain a benefit (a self-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 16 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, 1849 C Street, NW, Room
4559, Washington, DC 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 10/31/2021

Permit No.____________

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Self Bond Application