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Attached is a map showing the existing access routes proposed to be used for casual use exploration purposes, primary areas of interest,

and types of activities to be conducted.

The above described activities will be managed by:

Name __________________________________________________________________

Mailing Address _________________________________________________________

_________________________________________________________

Phone Number (include area code) ___________________________________________

Dated this _______________________ day of ___________________ , 20 _______ .

Signature of:

____________________________________________________

_____________________________________________________

(Person)

(Affiliate)

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.

RECORDER’S STAMP

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: 43 U.S.C. 299(b) and 43 CFR subpart 3814 and part 3838 permit collection of the information requested by this form.

PRINCIPAL PURPOSE: The BLM will use the information you provide to verify that you have complied with the pre-location requirements at

43 U.S.C. 299(b) and 43 CFR subpart 3814 and part 3838, and are therefore qualified to locate and record mining claims on land patented under the

Stock Raising Homestead Act.

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 43 U.S.C. 299(b) and 43 CFR subpart 3814

and part 3838 for mining claimants who desire to locate a mining claim or tunnel site on land previously patented under the Stock Raising Homestead Act.

Failure to comply and submit all the requested information or to complete this form will delay the BLM’s processing of the form or may preclude the

BLM’s acceptance of your notice of intent to locate (NOITL) a mining claim or site on lands patented under the Stock Raising Homestead Act. Failure to

comply with the requirements of 43 U.S.C. 299(b) and 43 CFR subpart 3814 and part 3838 will void your NOITL. Mining claims or sites located under a

void NOITL are null and void from the beginning and will be cancelled by the BLM.

The Paperwork Reduction Act requires us to tell you that:

The BLM collects this information to determine whether or not you are qualified to locate a lode or placer mining claim and/or tunnel site on lands

patented under the Stock Raising Homestead Act.

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 currently valid OMB control number.

BURDEN HOURS STATEMENT: Public reporting burden for this form is estimated to average 25 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 St., N.W., Mail Stop 401 LS, Washington, D.C. 20240.

(Form 3830-3, page 2)

Form 3830-3 - Notice Of Intent To Locate A Lode Or Placer Mining Claim(S) And/or A Tunnel Site - United States Department Of The Interior - Bureau Of Land Management - 2016 Page 2

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