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UNrT ED STATES <br /> t omi 383a2 DEPARTMENT'OF THE INTERIOR <br /> (January 2017) BUREAU OF LAND MANAGEMENT FORM APPROVED <br /> MAINTENANCE FEE WAIVER CERTIFICATION OMB NO. 1004-0114 <br /> ExpimR January 31,2020 <br /> SEE INSTRUCTIONS ON PAGE 2 <br /> 1. This small minerwaiver is Z led for the assessr>a t yearbe*t irg on September 1, and elrlinq on Sephernil>er 1, <br /> 2. The urndasigmd and all related parti owned ten orfewrr mining claims,mill,ortun located <br /> nel sites lod a m rntained on Federal ands in the United States <br /> of America on Sepbenber 1, .;,C/F <br /> 3. The urnd tsgned have perfortnad the assessrpnt work re#red by law for earn mining claim listed prior to Lling this waiver and understand that by ding taus form <br /> the undersigned test zle an affidavit of a>9essnnernt work with the Burg of Land Managanart(BLK by the Deoanber 30th following the i ling of taus waiver. <br /> 4. The uncietsig ned unierstand that if the asmss ter t work obligation has not yet come due under 30 U.S.C.28(for those claims in their i,PA asse%m-at year only), <br /> a notice of intent to hold reciting this condition mint be reoortied by the Deamixr30th following the Lling of this waiver. <br /> 5. The undersigned understand that mill and tunnel sites may also be listed on this waiver and be waived fiom payment of the rnainte nanoe fee,and that a notice of <br /> intent to hold for those sites is required to be Zled with the BLM by the Decern1mr 3Dth following the Zling of tins waver. <br /> 6. The urxiemigrred tuldast and aclaowledge tht pursuant to 43 U.S.C.1212 and 18 U.S.C.1001,the ding or recording of a false,Zctitious,orliaudlent <br /> docur nest with tine BLM may result in a i,ne of up to$250,000,a piste term not m exceed Zve years,orboth <br /> 7. The mining claims,mill or tilnrnd sites for which this waiver from peyrnant of the nx irnhernarne fees is requested are <br /> CLAIM OR SITE NAME BLM REC-OyRDATION SERIAL NUMBER <br /> 2. <br /> 5. <br /> Ca <br /> 7. <br /> a <br /> 9. <br /> 10. <br /> The owner(s)(dairr ants)of the above waning darns and sites are: <br /> (Owner's Name-Please Print) (Owrna' gn�ure) <br /> >11 6-v L/e- Cc,/ <br /> (Owner's MailingAddress) (City) (State) (Zip Code) <br /> ------------------------------------------------------------------------------------------------ <br /> (Owner's Name-Please Print) (Owner's Sign) <br /> —(Owna`sMadirngAddress) RECORDS UPDATE[) (zipcode) <br /> -------------------------------=------------------------------------------- ------- <br /> Action Code(s) <br /> (Owner's Name-Please Print) For 2-01 tgwtAWmenE Tear <br /> _ Rc t # qZq ? C, -1 _ <br /> (Owner's NFai dres) ---------- <br /> ---------------------------------- <br /> (Owner's I rIf IS Dad ) Z ) <br /> f 7 <br /> Name-Please Part) �' )1 +] , < �`� rJ J (Owner's Slg<naitne) -- <br /> 6J-I'�-lip <br /> (Owner's NWMAddiref) *747838* <br /> onnhrruedon page 2) 747838 7/23/2018 1:07 PM Debra A Green <br /> I of I R$8.75 D$0.00 Park County Clerk <br />