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(Owner's Name-Please Print) (Owner's Signature) <br /> (Owner's Mailing Address) (City) (State) (Zip Code) <br /> (Owner's Name-Please Print) (Owner's Signature) <br /> • <br /> (Owner's Mailing Address) (City) (State) (Zip Code) <br /> (Owner's Name-Please Print) (Owner's Signature) <br /> (Owner's Mailing Address) (City) (State) (Zip Code) <br /> (Owner's Name-Please Print) (Owner's Signature) <br /> (Owner's Mailing Address) (City) (State) (Zip Code) <br /> 18 U.S.C.1001 and 43 U.S.C.1212 make it a crime for any person knowingly and wailfully to make to any department or agency ofthe United States any <br /> false,fictitious or fraudulent statements or representations as to any matter within its jurisdiction. <br /> INSTRUC'TIONS <br /> I. 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 whidt this waiver is sought <br /> 3. The claimant(s)must fill in the date in paragraph 2 for the beginning oftbc assessment year for which this waiver is sought <br /> 4. All claim and site names and BLM serial numbers mast be listed for the mining deities,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 givers. <br /> 6. This waiver form must be signed by all the claimants or their designated agent,in original fora.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 roost 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 waiverno later than September 1,2011,in the proper BLM State Office.) <br /> B. For all mining claims which require assessment work,yon must record an affidavit of labor on or before the December 30th immediately following the <br /> Bing of this waiver.For all other mining claims or sites waived,you must record a notice of intent to hold on or before the December 30th immediately <br /> following the filing of this waiver <br /> 9. Mill and Cannel 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 /> • <br /> (Continued on page 3) - (Form 3830-2,page 2) <br />