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Executed this day of ,20 <br /> State of Principal <br /> County of By <br /> (Print name) <br /> Subscribed and sworn to before me this day <br /> Signature <br /> of 120 <br /> Title <br /> Business Address <br /> (Notary Public) <br /> (Date Commission Expires) (TIN or SSN No.,if applicable) <br /> Title 18 U.S.C. Section 1001 and Title 43 U.S.C. Section 1212 make it a crime for any person knowingly and willfully to make to any department or agency <br /> of the United States any false,fictitious,or fraudulent statements or representations as to any matter within its jurisdiction. <br /> If this bond is executed by a corporation,it should bear the seal of the corporation,if applicable. <br /> NOTICES <br /> The Privacy Act of 1974 and the regulation in 43 CFR 2.48(d)require that you be furnished the following information in connection with information <br /> required by this application. <br /> AUTHORITY: 30 U.S.C.22 et.seq.;43 U.S.C. 1732(b)and 1782(c);31 U.S.C.9301 et seq.;CFR 3802 and 43 CFR 3809. <br /> PRINCIPAL PURPOSE: Information is being used to establish financial responsibility for surface disturbance on public lands. <br /> ROUTINE USES: BLM will only disclose the information according to the regulations at 43 CFR 2.56(d). <br /> EFFECT OF NOT PROVIDING INFORMATION: Disclosure of the information is necessary to obtain or retain a benefit. Failure to disclose <br /> this information may result in the BLM's rejection of your application. <br /> The Paperwork Reduction Act of 1995 requires us to inform you that: <br /> The BLM collects this information to grant the right to conduct exploration and mining activities on public lands. <br /> Response to this request is required to obtain or retain a benefit. <br /> The BLM would like you to know that you do not have to respond to this or any other Federal agency-sponsored information collection unless it displays a <br /> currently valid OMB control number. <br /> BURDEN HOURS STATEMENT: Public reporting burden for this form is estimated to average about 8 hours per response,including the time for <br /> reviewing instructions,gathering and maintaining data,and completing and reviewing the form. Direct comments regarding the burden estimate or any <br /> other aspect of this form to U.S.Department of the Interior,Bureau of Land Management(1004-0194),Bureau Information Collection Clearance Officer <br /> (WO-630), 1849 C Street,N.W.,Room 2134LM,Washington D.C.20240. <br /> (Form 3809-2,page 2) <br />