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Forni 38304 UNITED STATES FORM APPROVED <br /> (January 2017) DEPARTMENT OF THE INTERIOR OMB NO.: 1004-0114 <br /> BUREAU OF LAND MANAGEMENT Expires:January 31,2020 <br /> AFFIDAVIT OF ANNUAL ASSESSMENT WORK <br /> 69978cp <br /> Page I of 3 <br /> Krastal. Browny Clerk. & Recorder <br /> Teller COL]flt9v Colorado RP $0u in <br /> WHEN RECORDED,MAIL DOCUMENT TO: 1_i ,_il2-�fi�I7 !I::-;A AM Recording Fee $19.2-5 <br /> NAME: �r� ./9 ✓L (JZ--- <br /> ADDRESS: �?a► r3 a o j <br /> CITY,STATE,ZIP: <br /> FOR COUNTY RECORDER'S USE <br /> No. of Claims <br /> x$10/claim <br /> 'i oG <br /> Total due BLM$ <br /> TO ALL WHOM IT MAY CONCERN: <br /> 1. 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, for the following contiguous unpatented mining claim(s), located in the County of <br /> % GLC/ , in the State of � . <br /> Tp Rg Sec Mer County Recordation Co.Recording <br /> BLM Serial No. Name of Claim Example: 13N SE 14 MDM Book and Page No. Date <br /> `7/ qj p 1 <br /> a,5/ 9!Z A It? -Z-f��d Q L)Ele* -714,d 2-7 d� <br /> �S> /< — 2— I c t VJ �2 106 <br /> N Q a) <br /> — 2— �� 5 1-71 1V 0C <br /> o c1 i S i i,t 3 j O T _ <br /> CD c <br /> r-) <br /> CD r LJ <br /> Ln <br /> '{7 <br /> (Continued on page 2) <br />