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PURCHASER <br />Ron Ebberts, Ebberts Construction <br />(Individual or Firm Name) <br />P.O. Box 250, Egnar, CO 81325 <br />(Address) <br />UNITED STATES OF AME A <br />B~~ucz ~eCL'a~ r~ <br />Y <br />/' (Authorized Officer) <br />GC'l~-~~~ 112 v0.~'> <br />(Title) <br />970-677-2476 <br />(Phone Number) i (Date) <br />s~ a <br />(Signature <br />(Signature) <br />If you are a corporation, affix corporate seal here. <br />Title 18 U.S.C. Section 1001, makes it a crime for any person knowingly or willfully to make to any department or agency of the <br />United States any false, fictitious or fraudulent statements or representations as to any matter within its jurisdiction, subject to a <br />fine of up to $10,000 and imprisonment up to 5 yeazs. <br />NOTICE <br />The Paperwork Reduction Act of 1995 (44 U.S.C. 3501 <br />et seq.) requires us to inform you that: <br />BLM is collecting this information to process your <br />application and effect a binding contract. <br />BLM will use this information to identify and <br />communicate with applicants. <br />You must respond to this request to get a bene£t. <br />A federal agency may not conduct or sponsor, and <br />you are not required to respond to, an information <br />collection which does not have a currently valid <br />OMB control number. <br />AUTHORITY: 30 U.S.C. 601 et seq,; 43 CFR 3600 <br />PRINCIPAL PURPOSE: BLM uses this information to <br />identify the parties entering into contracts for disposing of <br />mineral materials. <br />ROUTINE USES: BLM will transfer information from the <br />record or the record itself to appropriate federal, state, local, <br />or foreign agencies, when relevant to criminal, civil, or <br />regulatory investigations or prosecutions. <br />EFFECT OF NOT PROVIDING INFORMATION: If you <br />do not provide [his information to BLM, we will no[ be able <br />to process your application for a contract. <br />BLM estimates [he public reporting burden for this form at <br />an average of 30 minutes per response, including the time for <br />reviewing instructions, gathering and maintaining data, and <br />completing and reviewing the form. Direct comments <br />regarding the burden estimate or any other aspect of this <br />form to U.S. Deparhnent of the Interior, Bureau of Land <br />Management, Bureau Clearance Officer, (1004-0103), <br />1849 C St, NW., Mail Stop 401 LS, Washington, D.C. <br />20240. <br />