2017-12-04_REVISION - M2009056 (4)

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Boyd A.Astemborski Oplit;e:747...„-----7 (Owner's Name-Please Print) (Owner's Signature) 902 Collins Road Colorado Springs CO 80920 (Owner's Mailing Address) (City) (State) (Zip Code) Angie Pittman 4 . "'" . (Owner's Name-Please Print) (Owner's Signature) 902 Collins Road Colorado Springs CO 80920 (Owner's Mailing Address) (City) (State) (Zip Code) Bryan S. Pittman a1.- 7 (Owner's Name-Please Print) (Owner's Signature) 902 Collins Road Colorado Springs CO 80920 (Owner's Mailing Address) (City) (State) (Zip Code) (Owner's Name-Please Print) (Owner's Signature) (Owner's Mailing Address) (City) (State) (Zip Code) 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 false,fictitious or fraudulent statements or representations as to any matter within its jurisdiction. INSTRUCTIONS 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). 2. The claimants)must fill in the dates in paragraph 1 for the beginning and ending of the assessment year for which this waiver is sought. 3. The claimant(s)must fill in the date in paragraph 2 for the beginning of the assessment year for which this waiver is sought. 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. 5. All owners of the mining claims,mill sites,and tunnel sites and their addresses must be given. 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 agent,signed by all of the claimants with proper address given,must be submitted with this waiver. 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 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, you must qualify for and file for a waiver no later than September 1,2011,in the proper BLM State Office.) 8. For all mining claims which require assessment work,you must record an affidavit of labor on or before the December 30th immediately folloNying the 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 3ptb immst)f ly following the filing of this waiver. --- c-x .. 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 forgiese sites is required to be filed by the December 30th following the filing of this waiver. 74 .r, .7 -.j. '? :, FOR OFFICIAL USE ONLY REGGRgiewilitigub a -�1-4, (Continued on page 3) •,° ow ; to (Form 3830-2,page 2) -www sip .r... " I (3i '/2 - 7