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Stc. I5. SPECIAL STIPULATIONS (ConYdJ - <br />THE tiNITED STATES OF AMERICA <br /> <br />• <br /> <br />1~OTICE~ <br />The Privacy Act of 1974 and the regulation in 43 CFR 2.48(d) provide that you be furnished with the following information in connection <br />with information required by this application. <br />AUTHORITY: 30 U.S.C. 181-2$7 and 30 L'.S.C. 3~1-359. <br />PRINCIPAL PURPOSE: BLM will use the information you provide to process your application and determine if you are eligible to hold a <br />lease on BLM Land. <br />ROUTINE USES: BLM will only disclose the information according to the regulations at 43 CFR 2.~6(d), <br />EFFECT OF NOT PROVIDING INFORMATION: Disclosing the informs+~on is necessary to receive a benefit. No! disclosing the <br />information may result in BLdvI's rejecting your request for a lease. <br />The Paperwork Reduction Act of 1995 requires us to inform you that: <br />The BLM collects this information to authorize and evaluate proposed exploration and mining operations on public lands. <br />Response to the provisions of this lease form is mandatory for the types of activities specified. <br />The BLM would like you to know that you do not have to respond to this or any other Federal agency-sponsored information collection <br />unless it displays a currently valid OMB control number. <br />BURDEN HOURS STATEMENT: Pubtie repo~'~ing burden for this form is estimated to average one hour per response including the time <br />for reading the instructions and provisions, and completing and reviewing the form. Direct comments regarding the burden estimate or any <br />other aspect of this form to U.S. Department of the Interior, Bureau of Land Management (1004-0073}, Bureau Information Collection <br />Clearance Officer (WO-630), 1849 C Street, h~Iail Stop 401 LS, Washington, D.C. 20240. <br />(Porn 3aD0• I3, page 3) <br />fictitious or fraudulent statements or r.. resentat~ons as co an a:a~~~ w,~>«~~ ~~~ <br />