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a <br />The following parties have executed this contract as o£ <br />9% 1 Lot, A4414 <br />PURCHASER <br />3;e ?)(J- C-1 Q V *a,,JJ t-- <br />(Individual or Firm Name) <br />F0 S- P - 0VJ'-0-% <br />LLL <br />UNITED STATES OF AMERICA <br />By <br />t-/o/ <br />(Address) <br />9-70 <br />- ??? -®6 7 C <br />(Phone Number) <br />(Authorized Officer) <br />(Title) <br />(Date) <br />9-,;3 - to <br />(Signature) <br />(Signature) <br /> <br />Cl//3//() <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 <br />any department or agency of the United States any false, fictitious or fraudulent statements or <br />representations as to any matter within its jurisdiction, subject to a fine of up to $10,000 and <br />imprisonment up to 5 years. <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 />BLM will use this information to identify and <br />You must respond to this request to get a benefit. <br />A federal agency may not conduct or sponsor, and <br />you are not required to respond to, an information <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, or <br />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 this information to BLM, we will not be able to <br />process your application for a contract. <br />BLM estimates the public reporting burden for this form at an <br />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 form <br />to U.S. Department 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 />Attachment I - 5