Quartely Report Form For Small Mining Issues Form Page 2

STATE OF _______________ )

) ss:

COUNTY OF

)

On this _________ day of _________________, 20___, personally appeared before me, notary public in and for said county

and state, __________________________________________ who being first duly sworn, deposes and says that he is

______________________________ of _________________________________________ described in the foregoing report;

that he has read said report and all exhibits and statements filed therewith and made a part thereof and knows the contents

thereof and that the facts therein stated are true; that he has full authority to execute said report; and that said report is the free

act and deed of said registrant.

SUBSCRIBED AND SWORN to before me this ________ day of ______________________, 20____.

________________________________________________

NOTARY PUBLIC FOR STATE OF _________________________

Residing at:______________________________

My commission expires:___________________________

C:\MyFiles\Qtlyrptmine.wpd

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