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EXHIBIT G Sec. 18. Effective dare - This contract becomes effective as indicated below. Q If this contract becomes effective on the date BLM signs the contract, BLM will check this box. ❑ If this contract becomes effective only after certain conditions are met, BLM will check this box, list the conditions below, and indicate the effective date. Sec. 19. Appeal - You may appeal any decision that BLM makes in regard to this contract under Parts 4 and 1840 of Title 43 of the Code of Federal Regulations. The following parties have executed this contract as of. (Phone Number— include area code) (signature) (Signature) If you are a corporation, affix corporate seal here: W THE UNITED STATES OF AMERICA By Keith E. Berger (Print CaLM Official) (Signature 0!>Wllfficial) Field Manager, Royal Gorge Field Office (Title) (Date) Title 18 U.S.C. 1001, males it a crime for any person knowingly or willfully to make to any department or agency of the United States any false, fictitious or fraudulent statements orrepreserdations as to any matterwithin its jurisdiction, subject to a fine ofup to 510,000 and imprisonment up to 5 years. NOTICES The Privacy Act of 1974 and the regulation in 43 CFR 2.48(d) provide that you be furnished the following information in connection with information required by this application. AUTHORITY: 30 U.S.C. 601 et seq.; 43 CFR Group 3600 PRINCIPAL PURPOSE: BLM uses this information to identify the parties entering into contracts for disposing of mineral materials. ROUTINE USES: BLM will transfer information from the record or the record itself to appropriate Federal, State, local, or foreign agencies, when relevant to criminal, civil, or regulatory investigations or prosecutions. EFFECT OF NOT PROVIDING INFORMATION: If you do not provide this information to BLM, we will not be able to process your application for a contract. The Paperwork Reduction Act requires us to inform you that: The BLM is collecting this information to process your application and effect a binding contract. The BLM will use this information to identify and communicate with applicants. You must respond to this request to get a benefit. You do not have to respond to this or any other Federal agency -sponsored information collection unless it displays a valid OMB control number. BURDEN HOURS STATEMENT: Public reporting burden for this form is estimated to average about 1 hour per response, including the time for reviewing instructions, gathering and maintaining data, and completing and reviewing the form. You may submit comments regarding the burden estimate or any other aspect of this form to: U.S. Department of the Interior, Bureau of Land Management (1004-0103), Bureau Information Collection Clearance Officer (WO -630),1849 C Street, N.W., Room 2134LM, Washington, D.C. 20240. (Form MGM, page 3)