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*'I -61'A ES OF AMERICA <br />Helen M. 114nkins <br />State Director <br />Date: <br />Title 18 U.S.C. Section 1001, makes it a crime for any person knowingly and willfully to make to any department or agency of <br />the United States any false, fictitious or fraudulent statements or representations as to any matter within its jurisdiction: <br />NOTICES <br />The Privacy Act and 43 CFR 2.48(d) require that you be furnished with the following information in connection with the <br />information requested by this form. <br />AUTHORITY: 30 U.S.C. 181 - 287 and 30 U.S.C. 351 - 359 permit collection of the information requested by this form. <br />PRINCIPAL PURPOSE: The BLM will use the information you provide to process your application and determine if you <br />are eligible to hold a coal lease on public lands. <br />ROUTINE USES: The BLM will only disclose this information in accordance with the provisions at 43 CFR 2.56(b) and <br />(c). <br />EFFECT OF NOT PROVIDING INFORMATION: Submission of the requested information is necessary to obtain or <br />retain a benefit. Failure to submit all of the requested information or to complete this form may result in delay or preclude <br />the BLM's acceptance of your application for a coal lease. <br />The Paperwork Reduction Act requires us to inform you that: <br />The BLM collects this information to evaluate and authorize proposed exploration and mining operations on public lands. <br />Submission of the requested information is necessary to obtain or retain a benefit. <br />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: The public reporting burden for this form is estimated to average 25 hours per <br />response when the form is used under the authority of 43 subpart 3422 (Lease Sales), or 800 hours per response when the <br />form is used under the authority of 43 subpart 3430 (Preference Right Leases). The estimated burdens include the time <br />for reviewing instructions, gathering and maintaining data, and completing and reviewing the form. You may submit <br />comments regarding the burden estimate or any other aspect of this form to: U.S. Department of the interior, Bureau of <br />Land Management (1004-0073), Bureau Information Collection Clearance Officer (WO -630),1849 C Street, Mail Stop <br />401 LS, Washington, DC 20240. <br />4 <br />