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ted this day of L� <br /> grate of Principal <br /> County of By 1 Y`�N`(. - SV! C�`i <br /> (Print name) <br /> Subscribed and sworn to before me this day <br /> Signature <br /> ,_i�� <br /> of �_ 2 ) 2. <br /> � <br /> A. Title L c, ks,-� <br /> � <br /> Q MA <br /> Ljsiness Address <br /> ( otary P lic Sli <br /> 9 <br /> � 1=COLD <br /> Date Commissio lonl Expires <br /> ( P (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 /> W <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 wi1L 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 />