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(Owner's Name-Please Print) (Owner's Signature) <br /> (City) (State) (Zip Code) <br /> (Owners Mailing Address) <br /> (Owner's Signature) <br /> (Owner's Name-Please Print) _ <br /> 714 <br /> (owner's Mailing Address) <br /> (City) (State) (Zip Code) <br /> ------------j---------------------- <br /> -------------�---`-/------------------------------------------- <br /> 1L�-f.:�� (Owner/s ignature) <br /> (Owner's Name:Please Print) <br /> F0 ><LS!C OE (City) (State) (Zip Code) <br /> (Owner s Mailing Address) <br /> ----- � <br /> --------- --,---------------------------------------------- <br /> -- ---------------- <br /> MR" (Owner's signature) <br /> (Owner's Name-Please Pnnt) <br /> 12�c,o �/Q R.1�ort ST LAY-- (Z <br /> (Owners Mailing Address) <br /> (City) <br /> 18 U.S.C. 1001 and 43 U.S.C. 1212 make it a crime for any person knowingly and willfully to make to any department or agency of the United States any <br /> false,fictitious or fraudulent statements or representations as to any matter within its jurisdiction. <br /> INSTRUCTIONS <br /> 1. This certification is made under the provisions of 43 U.S.C.§ 1744 and 30 U.S.C.§28-28k and the regulations thereunder(43 CFR Part 3830). <br /> 2. The claimant(s)must fill in the dates in paragraph 1 for the beginning and ending of the assessment year for which this waiver is soughL <br /> 3. The claimants)must fill in the date in paragraph 2 for the beginning of the assessment year for which this waiver is sought. <br /> 4. All claim and site names and BLM serial numbers must be listed for the mining claims,mill sites,and tunnel sites for which the waiver is sought. <br /> 5. All owners of the mining claims,mill sites,and tunnel sites and their addresses must be given <br /> 6. This waiver form must be sighted by all the claimants or their designated agent,in original form.If an agent is designated,a notarized designation of <br /> agent,signed by all of the claimants with proper address given,must be submitted with this waiver. <br /> 7. This form must be filed no later than September 1st for the upcoming assessment year in the BLM State Office where the mining claims or sites are <br /> recorded,or the waiver cannot be granted by the BLM.(Example:To obtain a waiver for the assessment year 2012,which begins on September 1,2011, <br /> you must qualify for and file for a waiver no later than September 1,2011,in the proper BLM State Office.) _ <br /> 8. For all mining claims which require assessment work,you must rote must anaffidavit <br /> a officer norinte beet to re the d an ecMore the December Otfollowin the <br /> filing of this waiver.For all other mining claims or sites waived,y <br /> iately <br /> following the filing of this waiver. <br /> q Milt and amnel sites may also be listed on this waiver and be waived from payment of the maintenance fee.A notice of intent to hold for these sites is <br /> required to be filed by the December 30th following the filing of this waiver. <br /> FOR OFFICIAL USE ONLY <br /> (Form 3830-2,page 2) <br /> (Continued on page 3) <br />