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v . UNITED STATES , r7omx383Q DEPARTMENT OF THE INTERIOR -(Jatirtary 017) BUREAU OF LAND MANAGEMENT y FORM APPROVED MAINTENANCE FEE WAIVER CERTIFICATION OMB NO. 1004-0114 Expires: January 31,2020 SEE INSTRUCTIONS ON PAGE 2 1 -This'sttia1 miner waiver is filed for the assessment year beginning on September 1, 2017 and ending un September 1, 2018 jTheltnde}�7gned and all related parties owned ten or fewer mining claims,mill,or tunnel sites located mid maintained on Federal lands in the United States 1" "of America on September 1,2017 . 3. The undersigned have performed the assessment work required bylaw for each mining claim listed prior to filing this waiver and understand that by filing this form, the undersigned must file an affidavit of assessment work with the Bureau of Land Management(BLM)by the December 30th following the filing of this waiver. 4. The undersigned understand that if the assessment work obligation has not yet come due under 30 U.S.C.28(for those claims in their first assessment year only), a notice of intent to hold reciting this condition must be recorded by the December 30th following the filing of this waiver. 5. 'rhe undersigned understand that mill and tunnel sites may also be listed on this waiver and be waived from payment of die maintenance tee,and that a notice of l intent to hold for these sites is required to be filed with the BLM by the December 30th following the filing of this waiver. /� l 6. The undersigned understand and acknowledge that pursuant to 43 U.S.C.1212 and 18 U.S.C.1001,the filing or recording of a false,fictitious,or f raudule t v, document with the BLM may result in a fine of up to$250,000,a prison term not to exceed five years,or both. t J 7. The mining claims,mill or tunnel sites for which this waiver from payment ofthe maintenance fees is requested are- CLAIM OR SITE NAME BLM RECORDATION SERIAL NU--MBER I. OPEN#.1 CMC 245048 2. OPEN#2 CMC 245049 rU 3. xa +-c `- :�, 4. r� .YCrti 5. ,> 6. ` 7. 8. 9. ' 10. The owner(s)(claimants)of the above mining claims and sites are- R. Stanley Pittman,Jr. (Owner's Name-Please Print) (Own 's Signature) 902 Collins Road Colorado Springs CO 80920 (Owner's Mailing Address) (City) (State) (Zip Code) ---------------------------- --------------------- ------------ ------------ Sherryl K. Pittman 3 (Owner's Name-Please Print) 1 (Owner's Signature) 902 Collins Road Colorado Springs CO 80920 -----(Owner's Mailing Address) ----------- (City) (State) (Zip Code) -------------------------------------------------- - ------------- Harriett J. Pittman (Owner's Name-Please Print) (Owner's ' nature) 902 Collins Road Colorado Springs CO 80920 (Owner's Mailing Address) (City) (State) (Zip Code) -------- -�ku L . --- --------------- Amy R.Allmond (Owner's Name-Please Print) -5 902 Collins Road (Owner's Signature) Colorado, prin s CO 80920 (Owner's Mailing Address) (State) (Zip Code) (Continued on page 2)