3860-5 Application for Survey of Mining Claim

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Form 3860-5
(March 2019)

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FORM APPROVED
OMB NO. 1004-0025
Expires: March 31, 2022

UNITED STATES
DEPARTMENT OF THE INTERIOR
BUREAU OF LAND MANAGEMENT
APPLICATION FOR SURVEY ON MINING CLAIM

1. Name of Applicant (first, middle initial, last)

Date

SEE INSTRUCTIONS ON PAGE 2

Address (include zip code)

Hereby makes application for an official mineral survey of the mining claims named and identified in this application
2. Give group name (if any)

3. NAME OF CLAIM(S)
DATE
NAME OF LOCATION

LOCATED
AND
AMENDED

RECORDED
WITH
COUNTY

RECORDED
WITH
BLM

BLM
MINING
CLAIM
SERIAL
NUMBER

4. LOCATION OF CLAIM(S)
Township

Section
County

Range

Meridian

State

National Forest

5a. Is each claim based on a valid location and fully described in the certified copy of the record of each location certificate filed with this application?
Yes

No

b. Is each location distinctly marked by monuments on the ground and can its boundaries be traced readily?

Yes

No

No Survey of Mining Claim may be granted unless a completed Application form has been received (30 U.S.C. 21 through 54)
(Continued on page 2)

6. A deposit, is submitted with the application by
in the amount of $

cash

money order
certified check, made payable to the Bureau of Land Management,
, to cover the estimated cost of office work.

7. It is requested that the survey be made, in accordance with the regulations, by the following U.S. Mineral surveyor.

Date

Signature of Applicant

Title 18 U.S.C. Section 1001 and Title 43 U.S.C. Section 1212 make it a crime for any person knowingly and willfully to make 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 application is made under the provision of section 2325 of the
Revised Statutes, (30 U.S.C. 29), and the implementing regulations
(43 CFR 3861.1).
2. Applications must be typed or printed plainly in ink and subbmitted to
the State Director, Bureau of Land Management, having authority to
issue survey orders in that State as follows: Alaska, Anchorage;
Arizona, Phoenix; Arkansas and New Mexico, Santa Fe; California,
Sacramento; Colorado, Denver; North and South Dakota and
Montana, Billings; Nebraska, Kansas, and Wyoming, Cheyenne;
Idaho, Bosie; Nevada, Reno; Washington and Oregon, Portland; Utah,
Salt Lake City; all other States, Director, Bureau of Land Management,
Washington, D.C. 202040.

conflict or adjoining; locations joinging at a single corner are not
considered as contiguous.
6. A millsite may be applied for separately or in conjunction with the
survey of a mining claim. Millsites must be located on nonmineral
ground, may not embrace more than five acres in compact form, and
must be occupied or used in connection with mining activity.
7. Any change in the application for survey, including the addition or
exclusion of locations, or the designation of a different mineral
surveyor, requires an amended application which will be the basis for
issuance of an amended survey order.

3. Name the claimant (individual, partnership, company or corporation)
should appear on the application in the same manner as it will appear
in the patent when issued. The application must be signed by the
claimant or an authorized agent.

8. The claimant is required, in all cases, to select the mineral surveyor to
execute the survey from the Bureau of Land Management register of
mineral surveyors and to make satisfactory settlement arrangements for
payment for his services. The United States will not be responsible
for the settlement.

4. Two copies of the record of the location certificate must be filed with
the application, one of which must be certified by the custodian of
the records where mining claims are recorded, usually the Clerk of the
County in which the claim is located. Each certificate must contain
the name of the locator, date of location, point of discovery, and such
definite description of the claim by reference to natural objects or
permanent monuments as will serve to identify the claim on the
ground. If a location certificate has been amended and the survey is to
be based on the amended location, two copies of the latest amended
certficate are required with the application for survey, one of which
must be certified.

9. A minimum deposit of $750 for the first location, plus $300 for each
additional location or millsite to cover the cost of office expense, must
be made with the Bureau of Land Management before an order for the
survey will be issued. In accordance with CFR 43 Section 3861.6-1,
each State Office may require a deposit that is sufiicient to cover their
estimate of each order for survey. If this deposit is insufficient to cover
the actual cost of office work, the claimant will be billed for an
additional sum sufficient to cover the actual cost of drafting and other
office work in connection with processing the returns of the mineral
surveys. If the deposit is more than the actual cost, a refund will be
made to the claimant.

5. Applicants are requested to list in one application the contiguous
locations constituting the claim for which an official survey is desired.
Several locations may be embraced in as single survey only when they
are contiguous, by which is meant locations that are actually in

10. Mineral surveyors are precluded from acting, either directly or
indirectly, as agents or attorneys in proceedings to obtain patent for
mining claims. Interested parties are precluded from working on
mineral surveys as chainmen or field assistants.

(Continued on page 3)

(Form 3860-5, page 2)

NOTICES
THE PRIVACY ACT and the regulation in 43 CFR 2.48(d) provide that you be furnished the
following information in connection with information required by this application.
AUTHORITY: 30 U.S.C. 22, 29, 39, 43 CFR 3861.1.
PRINCIPAL PURPOSE: The information will be used to process your application for a mineral
survey.
ROUTINE USES: (1) The adjudication of the applicant’s rights to the land or resources; (2)
documentation for public information in support of notations made on land status records for the
management, disposal, and use of public lands and resources; (3) transfer to appropriate Federal
agencies when concurrence is required prior to granting a right in public lands or resources; and
(4) either specific information from the record or the complete record itself will be transferred to
appropriate Federal, State, local or foreign agencies, when relevant to civil, criminal or regulatory
investigations or prosecutions.
EFFECT OF NOT PROVIDING INFORMATION: The application may be rejected.
THE PAPERWORK REDUCTION ACT requires us to inform you that:
The BLM collects this information to properly provide the requested service. The information
provided will be used to determine the level of service required. 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 valid OMB control
number.
BURDEN HOURS STATEMENT: Public reporting burden for this form is estimated to average
4 hours 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
(1004-0025), Bureau Information Collection Clearance Officer (WO-630), 1849 C St., N.W., Room
2134LM, Washington, D.C. 20240.

(Form 3860-5, page 3)