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(0culbcr2013) BUREAU OF LAND MANAGEMENT FORM APPROVED <br /> MAINTENANCE FEE WAIVER CERTIFICATION OMB NO. 1004-0114 <br /> Expires: October 31,2016 <br /> SEE INSTRUCTIONS ON PAGE 2 <br /> 1. This small miner waiver is filed for the assesSn=1 year beginning on September 1, 20 j(—and ending on September 1,_2017 <br /> 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 <br /> of America on September 1,?016 <br /> 3. The undersigned have performed the assessment work required by law firr each mining claim listed prior to filing this waiver and understand that by filing this form, <br /> 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. <br /> 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), <br /> a notice of intent to hold reciting this condition must be recorded by the December 30th following the filing of this waiver. <br /> S. 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 <br /> intent to hold for these sites is required to be fled with the BLM by the December 30th following the filing of this waiver. <br /> 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 <br /> document with the BLM may result in a fine of up to$250,000,a prison term not to exceed five years,or both. <br /> 7. The mining claims,mill or tunnel sites for which this waiver from payment of the maintenance fees is requested are: <br /> CLAIM OR SITE NAME BLM RECORDATION SERIAL NUMBER <br /> I MC288.2-17-3 <br /> 2. <br /> 3. <br /> 4. <br /> 5. �v <br /> 6. 0 <br /> 7. — rn <br /> 8. <br /> 9. <br /> i7 <br /> 10. r• ,j� <br /> The owner(s)(claimants)of the above mining claims and sites we. ?- <br /> RLES O. S P I E L MAC_ <br /> (Owner's Name-Please Print) (Owner' Signature) <br /> Z70 S-A S 6i a ram A w A V F biJ-'r, Y 4 51'A -(_0_ 11+ <br /> (Owner's Mailing Address) (City) (State) (Zip Code) <br /> ,�-. "r <br /> Pww? 'TRIL�L-, iJ <br /> (Owner's,lame-Please Print) (Owner's Signature) <br /> 20 SS bidOj A ST eP- <br /> (Owner's Mailing Address) (City) te) (Zip Code) <br /> ----------------------------------------------------- ------------ -- -------------------- <br /> Si4 ZLYtA 1 R/LL <br /> (Owner's Name-Please Print) ( 's Signature) <br /> 20 .E 'DA,a ��A S-r 7i.���,u. �o ozo <br /> (Owner's Mailing Address) (City) (State) (Zip Code) <br /> A�-E Y-A fit DEAL -T&i L[ L I:f 0 <br /> - <br /> (Owner's Name-Please Print) (Owner's Signature) <br /> ZosS" DAHLIA Cr D"N MR ,� b o <br /> (Owner's Mailing Address) (City) (State) (Zip Code) <br /> (Continued on page 2) <br />