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11/14izuuo lo:la rA3 Lo1o444o%% D=LL ViL L %JAL UU41tuiv <br />NOTICES <br />The Privacy Act of 1974 and the regulation in 43 CFR 2.48(4) provide that you be famished with the following <br />information in connection with information required by this bond form. <br />AUTHORITY: 30 U.S.C.181 ct seq, 43 U.S.C. 3500 <br />PRINCIPAL PURPOSE: The Bureau of Land Management (BLM) will use the information you provide to ensure <br />that the United Statcs is fully indemnified against failure to perform under the terms, conditions, and stipulations of <br />a mineral lease. <br />ROUTINE USES: BLM will disclose information to: (1) appropriate Federal, state, local or foreign agencies, when <br />relevant to civil, criminal, or regulatory investigations or prosecutions; (2) appropriate Federal agencies when their <br />concurrence is required before BLM grants a right in public lands or resources: (3) a member of the public in <br />response to a specific request for pertinent information, (4) a congressional office in response to an inquiry made at <br />the request of an individual; and (5) to a consumer repotting agency to expedite collecting debts owed the <br />government <br />EFFECT OF NOT PROVIDING INFORMATION: Filing of this information is required to obtain and keep a <br />benefit. If you do not provide a bond,l3LM wlli not issue a use mineral lease. <br />The Paperwork Reduction Act of 1995 requires us to inform you that: <br />BLM collects this information to comply with the regulations at 43 CFR 3500, which implement the provisions of <br />the Mineral Leasing Act for of 1920, as amended; the Mineral Leasing Act for Acquired Land of 1947; and section <br />402 of Reorganization Plan No. 3 of 1946. <br />ELM uses the information to protect the interests of the United States in cases where lessees fail to perform under <br />the terms, conditions, and stipulations of their mineral leases or permits. <br />Response to this request is rcgaired to obtain and keep a benefit <br />BLM would like you to know that you do not have to respond to this or any other Federal agency-sponsored <br />information collection unless it displays a currcmly valid OM8 control number. <br />BURDEN HOURS STATEMENT: Public reporting burden for this form is estimated to average 4 hours per <br />response, including the time for reviewing instructions, gathering and maintaining data, and completing and <br />reviewing the form. Direct comments regarding the burden estimate or any other aspect of this form to U .S. <br />Department of the Interior, Bureau of Land Management, (1004-0121), Bureau. Information Collection Clearance <br />Officer (WO-630),,1849 C Street, N.W., Mail Stop 401 LS, Wasbington, D.C. 20240. <br />(Form 3504-3, page 2)