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County Recordation
Book and Page No
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Form 3830 -4
(October 2013)
(Continued on page 2)
UNITED STATES
DEPARTMENT OF THE INTERIOR
BUREAU OF LAND MANAGEMENT
AFFIDAVIT OF ANNUAL ASSESSMENT WORK
WHEN RECORDED, MAIL DOCUMENT TO:
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NAME: 7 1-75/-1 1 C (I �1i1
ADDRESS: 0 e3c (3 8- 7
CITY, STATE, ZIP: &)22 &Li
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TO ALL WHOM IT MAY CONCERN:
1. The undersigned certifies that at least $100 per claim was expended for development, labor and
improvements, or equivalent value added, as the annual assessment work for the assessment year ending
September 1,/ for the following contiguous unpatented mining claim(s), located in the County of
F-/,'N/C-&2/ in the State of 4' 0;1 ;4.6
FORM APPROb w
OMB NO.: 1004 -0114
Expires: October 31, 2016
0176
RECEIVED 12/11/2013 at 10:43 AM
RECEIVING 974469
BOOK: 825 PAGE: 176
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
FOR COUNTY RECORDER'S USE
No. of Claims
x $10 /claim
Total due BLM 1 2,
Description of Work Performed
Value of Work
Performed
Date Work Was
Performed
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2. Type of labor and improvements (specify what was done and give the total value for that labor and
improvement to show at least $100 for each claim). If a geological, geochemical, or geophysical survey was
performed, as per 30 U.S.C. 28 -1, reference the title of the report of survey, give cost and date of the survey
and report, and indicate it was filed with the County Recorder:
3. Name and mailing address of each person who performed the labor and improvements:
Name (please print) Current Mailing Address (please print)
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4. Name and mailing address of each person who holds and claims the subject mining claim(s) for the valuable
minerals contained therein. Be sure to indicate if there is a change of address:
C Name (please print)
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(Continued on page 3)
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Current Mailing Address (please print)
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5. The undersigned testifies that on the date of )7 7 j 20 12,- all monuments
required by law were erected upon the subject claim(s), and all notices required by law were posted on the
subject claim(s) or copies thereof were in place, and at said date, each corner monument bore or contained
Form 3830 -4, page 2)
markings sufficient to appropriately designate the corner of the claim to which it pertains and the name of the
claim(s).
I hereby ce ify under penalty of perjury under the laws of the State of lif e that the
foregoing Yatements are true c R A orr ct:
Signature of person responsible for above statement
Title 18 U.S.C. 1001 and 43 U.S.C. 1212 make it a crime for any person knowingly and willfully to make to any department or
agency of the United States any false, fictitious or fraudulent statements or representations as to any matter within its jurisdiction.
SUBSCRIBED AND SW RN TO before me, this
By:
f\
J (Signature of Affiant)
Title: 1 ck y 1���
My Commission Expires:
Notary Block
IC day of
Date:
INSTRUCTIONS
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My Commission Expires
1. This is an optional form that may be used to satisfy the requirements for the Bureau of Land Management (BLM)
under the provisions of 43 U.S.C. 1744 and 30 U.S.C. §28 -28d and the regulations thereunder (43 CFR part
3835). Since local and State laws may vary, you should contact your local and State agencies where the claims
are located to ensure all applicable laws and requirements are satisfied.
2. The claimant(s) must fill in the date in paragraph 1 for the applicable assessment year and the county and state
where the claims are located.
3. All claim names, BLM serial numbers, legal descriptions, and original county recording information must be
listed for the claims pertaining to this assessment notice.
4. The claimant(s) must complete paragraph 2 listing all labor or improvements which was performed on or did
benefit the subject mining claims. The value and date of the labor or improvements must also be listed. The total
amount of labor or improvements can be listed, but the total expenditure must equal at least $100 for each claim.
5. The names and current mailing addresses of the person(s) performing the labor shall be listed in paragraph 3.
6. The name and current mailing address of each owner (claimant) of the claims shall be listed in paragraph 4. The
mailing address shall be the owner's address and not the address of an agent or anyone representing the claimant.
Be sure to note if there has been a change of address.
7. Paragraph 5 shall be completed to show the date it was verified that all monuments required by law were properly
erected, all notices were posted, and that corners were appropriately designated for all claims listed.
8. An exact legible reproduction or duplicate (other than microfilm or other electronic media) of this affidavit or
another type of affidavit of assessment work that you file or will file in the county where each claim is located,
must be filed with the BLM on or before December 30 of the calendar year in which the assessment year ends.
For mill or tunnel sites, a separate notice of intent to hold must be filed with the BLM on or before December 30.
Requirements for filing a notice of intent to hold can be found at 43 CFR 3835.33.
9. A processing fee of $10 for each claim listed must be remitted to the BLM along with this or any other affidavit
of assessment work.
(Continued on page 4) Form 3830 -4, page 3)