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NOTICES <br /> THE PRIVACY ACT and 43 CFR 2.223(d)require that you be furnished with the following information in <br /> connection with the information requested by this form. <br /> AUTHORITY: 30 U.S.C. §28-28d and 43 CFR part 3835 permit collection of the information requested by <br /> this form. <br /> PRINCIPAL PURPOSE: The BLM will use the information you provide to document compliance with 43 <br /> U.S.C. 1744 and that assessment work has been completed in accordance with 30 U.S.C. §28-28d and 43 CFR <br /> part 3835 in lieu of paying the maintenance fee for the mining claims listed on this form. <br /> ROUTINE USES: The BLM will only disclose this information in accordance with the provisions at 43 CFR <br /> 2.231(b)and(c). <br /> EFFECT OF NOT PROVIDING INFORMATION: Disclosure of the requested information is required by <br /> 30 U.S.C. §28-28d and 43 CFR part 3835 for claimants qualified to perform assessment work in lieu of paying <br /> the maintenance fee. Failure to submit all the requested information or to complete this form will delay the <br /> BLM's processing of the form and may preclude the BLM's acceptance of the assessment work information, <br /> which may result in forfeiture of the mining claim(s)by the claimant. <br /> THE PAPERWORK REDUCTION ACT requires us to inform you that: <br /> Use of this form is optional. You must perform assessment if a waiver to pay the maintenance fee has been <br /> requested. This form is provided to help you attest that annual assessment work has been completed in lieu of <br /> paying the maintenance fee for your claim(s). Submission of the requested information is necessary to obtain or <br /> retain a benefit. <br /> You do not have to respond to this or any other Federal agency-sponsored information collection unless it <br /> displays a valid OMB control number. <br /> BURDEN HOURS STATEMENT: The estimated public reporting burden for this form is 30 minutes per <br /> response,including the time for reviewing instructions,gathering and maintaining data,and completing and <br /> reviewing the form. You may submit comments regarding the burden estimate or any other aspect of this form <br /> to: U.S.Department of the Interior,Bureau of Land Management(1004-0114),Bureau Information Collection <br /> Clearance Officer(W0-630), 1849 C Street,N.W.,Room 2134LM,Washington,D.C. 20240. <br /> (Form 3830-4,page 4) <br />