Maintenance Fee Payment For Lode Claims, Mill Sites, And Tunnel Sites Form (Page 2 of 3) in pdf

Maintenance Fee Payment For Lode Claims, Mill Sites, And Tunnel Sites Form Page 2

CLAIM/SITE NAME

BLM SERIAL NO.

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Note: Use a separate sheet for additional claim names, serial numbers, and claimant names and addresses.

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. 28f and 43 CFR 3834 permit collection of the information requested by this form.

PRINCIPAL PURPOSE: The BLM will use the information you provide to record the annual maintenance fee payment for the claim(s)

or site(s) listed and to verify that payment has been made in accordance with 30 U.S.C. 28f and 43 CFR part 3834.

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. 28f and 43 CFR part

3834 for claimants paying the annual maintenance fee. The use of this specific form when paying the maintenance fee is optional.

However, when paying the maintenance fee, it is the requested information on this form that is required to be submitted along with

the fee. Failure to submit all the required information will delay the BLM’s processing of the information and may preclude the

BLM’s acceptance of the maintenance fee payment, which may result in forfeiture of the mining claim(s) or site(s) by the claimant.

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Maintenance Fee Payment For Lode Claims, Mill Sites, And Tunnel Sites Form Page 2