Form 3504-1 - Personal Bond And Power Of Attorney Under Mineral Lease Or Prospecting Permit For Mining Deposits

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Form 3504-1

(Aug 2016)

FORM APPROVED

UNITED STATES DEPARTMENT OF

OMB NO. 1004-0121

THE INTERIOR BUREAU OF LAND

Expires: August 31, 2019

MANAGEMENT

Serial Number

PERSONAL BOND* AND POWER OF ATTORNEY

Bond Number

UNDER

MINERAL LEASE OR

PROSPECTING PERMIT

FOR MINING DEPOSITS

Office

Know All Men By These Presents, That

, as obligor, is 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, he binds himself,

his heirs, executors, administrators, and successors, jointly and severally, firmly by these presents.

The conditions of this obligation are such, that whereas the above-named obligor entered into a mineral lease or prospecting permit of the

lands described therein upon conditions therein expressed, which mineral lease or prospecting permit bears the above serial number.

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

the requirements of said mineral lease or prospecting permit and will duly keep, perform, and abide by each and every term and provision

of said mineral lease or prospecting permit as therein stipulated and agreed, then this obligation will be null and void; otherwise to remain

in full force and effect.

That said obligor, in order the more fully to secure the United States in the payment of the aforesaid sum, hereby pledges cash as security

therefor or negotiable bonds of the United States, of a par value equal to the amount specified, which said bonds are numbered serially and

are in the denominations and amounts and are otherwise more particularly described as follows:

bonds of $

, bearing

percent interest, with coupons attached to each numbered

which said bonds have been deposited with the Secretary of the Interior.

* This form of bond may be used in connection with phosphate, and sodium mineral leases or prospecting permits, Act of February 25, 1920, as amended

(30 U.S.C. 181 et seq.); potassium mineral leases or prospecting permits, Act of February 7, 1927, as amended (30 U.S.C. 281 et seq.); sulphur mineral

leases or prospecting permits, Act of April 17, 1926, as amended (30 U.S.C. 271 et seq.); all such mineral leases or prospecting permits involving acquired

lands, Act of August 7, 1947, (30 U.S.C. 351), and asphalt mineral leases or prospecting permits, Act of June 28, 1944, as amended (25 U.S.C. 561–562),

by inserting the particular mineral applicable in the space provided therefor. This form is for use where the mineral lease or prospecting permit covers either

public lands or lands embraced in an entry or patent subject to the reservation of potassium, phosphate, or sodium deposits to the United States under the Act

of July 17, 1914 (30 U.S.C. 121–123); pursuant to the Act of June 22, 1910 (30 U.S.C. 83–85), pursuant to the Act of March 8, 1922 (48 U.S.C. 376–377);

or of sulphur pursuant to the Act of March 4, 1933 (30 U.S.C. 124). If this bond is executed by a corporation, it must bear the corporate seal.

(Continued on page 2)

(Form 3504-1, page 1)