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Form 3830-4 UNITED STATES FORM APPROVED <br /> • • (1� y 201 7) DEPARTMENT OF THE INTERIOR OMB NO.:1004-0114 <br /> BUREAU OF LAND MANAGEMENT Expires:January 31,2020 <br /> AFFIDAVIT OF ANNUAL ASSESSMENT WORK <br /> WHEN RECORDED,MAIL DOCUMENT TO: ram <br /> w ° V: <br /> xiy Nnl <br /> NAME:J E FE Fa t2 t3 C5 T cam, -1>o>o <br /> f m O--+ <br /> ADDRESS: SO 5-'1 S. V F it m t;SO P E 1kK- <br /> r;x <br /> •- <br /> CITY,STATE,ZIP: LI!TL€"fdt; L`0. 5--'O1a`/ fU :ayA: <br /> FOR COUNTY RECORDER'S US E;`� ;, <br /> No.of Claims <br /> x$10/claim r <br /> Total due BLM S f/D•o U <br /> TO ALL WHOM IT MAY CONCERN: <br /> I. The undersigned certifies that at least $100 per claim was expended for development, labor and <br /> improvements, or equivalent value added, as the annual assessment work for the assessment year ending <br /> September 1, 2017 for the following contiguous unpatented mining claim(s), located in the County of <br /> 7-E t_L E R ,in the State of Co Lee n DO <br /> • . _ Tp Eg Sec.. Mar..- CongtyReeordatiou Co.Recording <br /> BLM Serial No. Name of Claim -Example;13N:54 14MDM ._ :Book and-Page No. Date, <br /> ,15.13 _ 5ruACttfr LoA0-4 t 11S <br /> 2SS3S S SheaFrrr" Lon N# 2- /25 1,w <br /> , 725"Is Ruff' - AD4k t 135 Irv, a 4 <br /> '9114 1( nALC-Vfval.) 1+ I r 71 N! a G <br /> (Continued on page 2) <br />