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markings sufficient to appropriately designate the corner of the claim to which it pertains and the name of the <br /> claim(s). <br /> 1 hereby certify under penalty of perjury under the laws of the State of e,01,4 ,a i4 D o that the <br /> foregoing statements are true and correct: <br /> (-ILTA,� C!.. a-r�,e a Date: FF I7 117 <br /> (Signage of person responsible for above statement) <br /> Title 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 <br /> agency ofthe United States any false,fictitious or fraudulent statements or representations as to any matter within its jurisdiction. <br /> Notary Block <br /> SUBSCRIBED AND SWORN TO before me,this day of 20 o�4r <br /> o r� <br /> y„ vim' <br /> -1" <br /> By: � <br /> (Signature of Affiant) t;7 G` <br /> Title: <br /> Z� <br /> My Commission Expires: iv I,V.j�,,:i, <br /> cry <sx� <br /> m—+ <br /> 7d <br /> INSTRUCTIONS <br /> 1. This is an optional form that may be used to satisfy the requirements for the Bureau of Land Management(BLM) <br /> under the provisions of 43 U.S.C.§1744 and 30 U.S.C.§28-28d and the regulations thereunder(43 CFR part <br /> 3835). Since local and State laws may vary,you should contact your local and State agencies where the claims <br /> are located to ensure all applicable laws and requirements are satisfied. <br /> 2. The claimant(s)must fill in the date in paragraph I for the applicable assessment year and the county and state <br /> where the claims are located. <br /> 3. All claim names,ELM serial numbers,legal descriptions,and original county recording information must be <br /> listed for the claims pertaining to this assessment notice. <br /> 4. The claimant(s)must complete paragraph 2 listing all labor or improvements which was performed on or did <br /> benefit the subject mining claims. The value and date of the labor or improvements must also be listed. The total <br /> amount of labor or improvements can be listed,but the total expenditure must equal at least$100 for each claim. <br /> 5. The names and current mailing addresses of the person(s)performing the labor shall be listed in paragraph 3. <br /> 6. The name and current mailing address of each owner(claimant)of the claims shall be listed in paragraph 4. The <br /> mailing address shall be the owner's address and not the address clan agent or anyone representing the claimant. <br /> Be sure to note if there has been a change of address. <br /> 7. Paragraph 5 shall be completed to show the date it was verified that all monuments required by law were properly <br /> erected,all notices were posted,and that corners were appropriately designated for all claims listed. <br /> 8. An exact legible reproduction or duplicate(other than microfilm or other electronic media)of this affidavit or <br /> another type of affidavit of assessment work that you file or will file in the county where each claim is located, <br /> must be filed with the BLM on or before December 30 of the calendar year in which the assessment year ends. <br /> For mill or tunnel sites,a separate notice of intent to hold must be filed with the BLM on or before December 30. <br /> Requirements for filing a notice of intent to hold can be found at 43 CFR 3835.33. <br /> 9. A processing fee of$10 for each claim listed must be remitted to the BLM along with this or any other affidavit <br /> of assessment work. <br /> (Continued on page 4) (Form 38344,page 3) <br />