Form 3809-4a - Surface Management Personal Bond Rider
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UNITED STATES
Form 3809-4a
FORM APPROVED OMB
(January 2017)
DEPARTMENT OF THE INTERIOR
No. 1004-0194 Expires:
BUREAU OF LAND MANAGEMENT
January 31, 2020
SURFACE MANAGEMENT PERSONAL BOND RIDER
In consideration for this rider and the acceptance of this rider by the Bureau of Land Management (BLM) on behalf of the United States of
America, this rider attaches to and is part of Surface Management Bond No.
issued on behalf of
principal, in favor of the United States. The bond provides coverage as shown below:
; Nationwide
Individual
; Statewide
(Enter State Name, if applicable)
(Enter “Yes”, if applicable)
(Enter BLM Serial No.)
Increase/Decrease in Dollar Amount of Bond Coverage
It is understood and agreed that
, principal, is increasing/decreasing the
coverage of this bond to the amount shown below; however, this rider will not act to increase/decrease the actual cumulative or potential
liability above the face amount of the bond, to wit:
).
U.S. dollars ($
Statewide/Nationwide Bond
The principal hereby agrees to and extends bond coverage to include any and all operations under 43 CFR 3802 and 43 CFR 3809.
.
Include name of State if coverage is Statewide
Bond Coverage Extended
The principal hereby agrees to and extends bond coverage to include notice-level operations pursuant to regulations at 43 CFR 3809.
Third Party Posting of the Financial Instrument for the Bond
It is understood and agreed that
is pledging the financial instrument
to secure the attached bond on behalf of
, operator and principal on the bond.
Coprincipal
It is understood and agreed that
, principal, is extending the coverage of the
bond referenced above to include liabilities for operations conducted by
on notice/plan of
.
operations serialized
(Continued on page 2)
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