HomeMy WebLinkAbout978192Form 3830 -4
WHEN RECORDED, MAIL DOCUMENT TO:
NAME
ADDRES
UNITED STATES
DEPARTMENT OF THE INTERIOR
BUREAU OF LAND MANAGEMENT
AFFIDAVIT OF ANNUAL ASSESSMENT WORK
/2q.
CITY, STATE, ZIP: 4 /YJG'%
O
TO ALL WHOM IT MAY CONCERN:
(Continued on page 2)
FORM APPROVED
OMB NO.: 1004 -0114
Expires:
978192 8/29/2014 2:25 PM
LINCOLN COUNTY FEES: $21.00 PAGE 1 OF 4
BOOK: 838 PAGE: 609 AFFIDAVIT
JEANNE WAGNER LINCOLN COUNTY CLERK
111111111111111111111111111111111111111111111111EN 11111111111111111111111
FOR COUNTY RECORDER'S USE
No. of Claims
x $10 /claim
Total due BLM
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, 19/ f for the following contiguous unpatented mining claim(s), located in the County of
COLAJ in the State of U nY1•a
«sa w
Name of Claim
(,06-)9e
Tp Rg Sec Mer
Example:; 14 MDM
03/
County Recordation
Book and Page No,
2. Type of labor and improvements (specify what was done and give the total value for that labor and
improvement to show at least 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:
Description of Work Performed
Value•of Work
Performed
c)
3. Name and mailing address of each person who performed the labor and improvements:
Name (please print)
Name (please print)
(Continued on page 3)
Current Mailing Address (please print)
N aorik6-Iggz
r et r7o,d9
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:
Cu rent Mailing Address (please print)
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5. The undersigned testifies that on the date of 20 /3 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
I hereby certi under penalty of p under the laves of the State of a iat the
claim(s).
foregoing st ments are a and co
ignature 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 wilfully to make to any department or
agency of the United States any fal fictitious or fraudulent statements or representations as to any matter within its jurisdiction.
SUB BED AND WORN TO before me, this (l
By:
nature of Affiant)
Title:'
My Commission Expires:
Notary Block
day of`
/V
INSTRUCTIONS
Date: //jfr )66
SHONDA HILL NOTARY PUBLIC
County of y f, State of
Lincoln W„yomiOC
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 claimants) 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)
NOTICES
THE PRIVACY ACT and 43 CFR 2.48(d) require that you be furnished with the following information in
connection with the information requested by this form.
AUTHORITY: 30 U.S.C. §28 -28d and 43 CFR part 3835 permit collection of the information requested by
this form.
PRINCIPAL PURPOSE: The BLM will use the information you provide to document compliance with 43
U.S.C. 1744 and that assessment work has been completed in accordance with 30 U.S.C. 28 -28d and 43 CFR
part 3835 in lieu of paying the maintenance fee for the mining claims listed on this form.
ROUTINE USES: The BLM will only disclose this information in accordance with the provisions at 43 CFR
2.56(b) and (c).
EFFECT OF NOT PROVIDING INFORMATION: Disclosure of the requested information is required by
30 U.S.C. 28 -28d and 43 CFR part 3835 for claimants qualified to perform assessment work in lieu of paying
the maintenance fee. Failure to submit all the requested information or to complete this form will delay the
BLM's processing of the form and may preclude the BLM's acceptance of the assessment work information,
which may result in forfeiture. of.tliemining claim(s) by the claimant.
THE PAPERWORK RIEDUCTION ACT requires us to inform you that:
Use of this form is" optional:; -'You must perform assessment if a waiver to pay the maintenance fee has been
requested This form is provided to help you attest that annual assessment work has been completed in lieu of
paying the maintenance fee for your claim(s). Submission of the requested information is necessary to obtain or
retain a benefit.
You do not have to respond to this or any other Federal agency- sponsored information collection unless it
displays a valid OMB control number.
BURDEN HOURS STATEMENT: The estimated public reporting burden for this form is 30 minutes per
response, including the time for reviewing instructions, gathering and maintaining data, and completing and
reviewing the form. You may submit comments regarding the burden estimate or any other aspect of this form
to: U.S. Department of the Interior, Bureau of Land Management (1004- 0114), Bureau Information. Collection
Clearance Officer (WO -630), 1849 C Street, N.W., Room 2134LM, Washington, D.C. 20240.
(Form 3830 -4, page 4)