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lti . , <br /> ;nil, <br /> �' <br /> BoysluA:�Ptsfemborski <br /> 4...----7 <br /> (Owner's Name-Please Print) , (Owner's Signature) <br /> 902 Collins Road Colorado Springs CO 80920 <br /> (Owner's Mailing Address) <br /> (City) (State) (Zip Code) <br /> Angie Pittman <br /> (Owner's Name-Please Print) / (Owner's Signature) <br /> 902 Collins Road Colorado Springs CO 80920 <br /> (Owner's Mailing Address) (City) (State) (Zip Code) <br /> Bryan S. Pittman <br /> , — ,j7 r <br /> (Owner's Name-Please Print) (Owner's Signature) <br /> 902 Collins Road Colorado Springs CO 80920 <br /> (Owner's Mailing Address) (City) (State) (Zip Code) <br /> (Owner's Name-Please Print) (Owner's Signature) <br /> (Owner's Mailing Address) (City)t3' (State) (Zip Code) <br /> 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 agency of the United States any <br /> false,fictitious or fraudulent statements or representations as to any matter within its jurisdiction. <br /> INSTRUCTIONS <br /> 1. This certification is made under the provisions of 43 U.S.C.§1744 and 30 U.S.C.§28-28k and the regulations thereunder(43 CFR Part 3830). <br /> 2. The claimant(s)must fill in the dates in paragraph I for the beginning and ending of the assessment year for which this waiver is sought. <br /> 3. The claimants)must fill in the date in paragraph 2 for the beginning of the assessment year for which this waiver is sought. <br /> 4. All claim and site names and BLM serial numbers must be listed for the mining claims,mill sites,and tunnel sites for which the waiver is sought. <br /> 5. All owners of the mining claims,mill sites,and tunnel sites and their addresses must be given. <br /> 6. This waiver form must be signed by all the claimants or their designated agent,in original form.If an agent is designated,a notarized designation of <br /> agent,signed by all of the claimants with proper address given,must be submitted with this waiver. <br /> 7. This form must be filed no later than September 1st for the upcoming assessment year in the BLM State Office where the mining claims or sites are <br /> recorded,or the waiver cannot be granted by the BLM.(Example:To obtain a waiver for the assessment year 2012,which begins on September 1,2011, <br /> you must qualify for and file for a waiver no later than September 1,2011.in the proper BLM State Office.) <br /> 8. For all mining claims which require assessment work,you must record an affidavit of labor on or before the December 30th immediately following the <br /> filing of this waiver.For all other mining claims or sites waived,you must record a notice of intent to hold on or before the December 30th immcdAa aly <br /> following the filing of this waiver. r _�_ <br /> 9. Mill and tunnel sites may also be listed on this waiver and be waived from payment of the maintenance fee.A notice of intent to hold for'tlrese sites is <br /> required to be filed by the December 30th following the filing of this waiver. ?b __,:-c <br /> rt7 <br /> ril , ' <br /> (_ri <br /> r") <br /> ; <br /> ) <br /> C.•,, <br /> vJ -`l7 <br /> tr'"� <br /> � FOR OFFICIAL USE ONLY <br /> R R $twitatQb <br /> �G '----. i;3 <br /> mz <br /> (Continued on page 3) <br /> N.I .J�� .!1.5.:611it. ' .� to (Form 3830.2,page 2) <br /> Gip,, <br /> 4 iO- /O-/2 /7 <br />