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Form 3830-4 UNITED STATES FORM APPROVED <br /> (January 2017) DEPARTMENT OF THE INTERIOR OMB NO.:1004-0114 <br /> BUREAU OF LAND MANAGEMENT Expires:January 31,2020 <br /> AFFIDAVIT OF ANNUAL ASSESSMENT WORK <br /> WHEN RECORDED,MAIL DOCUMENT TO: <br /> NAME: Robert Berry <br /> ADDRESS: 3871 Black Feather Trail <br /> CITY,STATE,ZIP: Castle Rock, CO 80104 <br /> FOR COUNTY RECORDER'S USE <br /> No.of Claims <br /> x$15/claim <br /> Total due BLM$ 15 <br /> TO ALL WHOM IT MAY CONCERN: <br /> 1. The undersigned certifies that at least $100 per claim was expended for development, labor and <br /> improvements, or equivalent value added, as the annual assessment work for the assessment year ending <br /> September 1, 2019 for the following contiguous unpatented mining claim(s), located in the County of <br /> Park ,in the State of Colorado <br /> TO Rg Sec Mer County Recordation I Co-According <br /> BLM Serial No. Name of Claim Example:13N SE 14 MDM Book and Page No. r � <br /> CMC287911 Robert Michael #1 15S 76W 35 NE Park - 721302 1 5 <br /> nc7—+ <br /> (Continued-page 2) <br />