Form 3504-3 - Bond Under Lease For Mining Deposits

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Form 3504-3

FORM APPROVED

(Aug 2016)

UNITED STATES DEPARTMENT OF

OMB NO. 1004-0029

THE INTERIOR BUREAU OF LAND

Expires: August 31, 2019

MANAGEMENT

Serial Number

BOND* UNDER LEASE FOR

Bond Number

MINING DEPOSITS

Know All Men By These Presents, That

, as principal,

and

, as surety,

are held and firmly bound unto the United States in the sum of

dollars

), lawful money of the United States, for the payment of which, well and truly to be made, we bind ourselves,

and each of us, and each of our heirs, executors, administrators, and successors, jointly and severally, firmly by these presents

The conditions of this obligation are such, that whereas the said principal entered into a lease of the lands described therein and upon condi-

tions therein expressed, which lease bears the above serial number.

Now, Therefore, if the said principal, his heirs, executors, administrators, or successors, will faithfully carry out the obligations and observe

the requirements of said lease, and will duly keep, perform, and abide by each and every term and provision of said lease as therein stipulated

and agreed, then this obligation will be null and void; otherwise to remain in full force and effect.

Signed on this

day of

, 20

, in the presence of:

(Signature of Witness)

(Printed Name of Witness)

(Signature of Principal)

(Printed Name of Signer)

(Address of Witness)

(Address of Principal)

(Signature of Witness)

(Printed Name of Witness)

(Signature of Surety)

(Printed Name of Signer)

(Address of Witness)

(Address of Surety)

(Signature of Witness)

(Printed Name of Witness)

(Signature of Surety)

(Printed Name of Signer)

(Address of Witness)

(Address of Surety)

Title 18 U.S.C. Section 1001 and Title 43 U.S.C. Section 1212, make it a crime for any person knowingly and willfully to make to any de-

partment or agency of the United States any false, fictitious or fraudulent statements or representations as to any matter within its jurisdiction

* This form of bond may be used in connection with coal, phosphate, and sodium leases, Act of February 25, 1920, as amended (30 U.S.C. 181 et seq.);

potassium leases, Act of February 7, 1927, as amended (30 U.S.C. 281 et seq.); sulphur leases, Act of April 17, 1926, as amended (30 U.S.C. 271 et seq.); all

such leases involving acquired lands, Act of August 7, 1947 (30 U.S.C. 351), and asphalt leases, Act of June 28, 1944 (58 Stat. 463, 483-485), by inserting

the particular mineral applicable in the space provided therefore. If this bond is executed by a corporation, it must bear the corporate seal.

(Continued on page 2)

(Form 3504-3, page 1)