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3113f1-005 <br /> UNITED STATES <br /> DEPARTMENT OF THE INTERIOR <br /> BUREAU OF LAND MANAGEMENT <br /> MAINTENANCE FEE PAYMENT FORM <br /> FOR LODE CLAIMS, MILL SITES,AND TUNNELSITIS=• <br /> G O A a <br /> Claimant Name: /3i'4t Ae 1/1: <br /> 49 <br /> , A <br /> Mailing Address: / {9 &.i/ 'toecv Or <br /> City, State, Zip: du to/In- ^ /5 <br /> Check here if this is a change of address. <br /> FOR COUNTY RECORDER'S USE <br /> No. of claims/sites 9 <br /> x $200 per claim/site O`D <br /> Total due BLM $ 0 <br /> 1. The maintenance fee may be paid by cash, check, money order, or credit card (VISA, American Express, <br /> Discover, or MasterCard). Payments must be submitted to the BLM State Office where your claim or site is <br /> recorded and received on or before September 1. If the payment is mailed, the envelope must be postmarked by <br /> a bona fide delivery service on or before September 1 and received at the BLM State Office within 15 calendar <br /> days after the due date. A complete listing of BLM State Offices with their addresses and phone numbers can be <br /> found at http://www.blm.gov. Payments may be made by telephone using a credit card if documentation of <br /> which claims are being paid is submitted separately, via mail or electronic delivery. You may also pay the <br /> maintenance fee online using the Mineral and Land Records System (https://mlrs.blm.gov) (MLRS) by creating <br /> a user account(or using an account you have already created) and following the prompts from your account <br /> page, using either a credit card or ACII payment. <br /> 2. The maintenance fee for the following claims)/site(s) applies to the assessment year .©(‘- Lj <br /> CLAIM/SITE NAME BLM SERIAL NO. <br /> 13 hie DI A Apt.e.iud Co 3 '7 7 <br /> Fv' ,uc rl o e dt ��. ' '99 7 <br /> Use a separate sheet for additional claim/site names,serial numbers,and claimant names and addresses. <br /> (Continued on Page 2) (Form 3830-5) <br />