Form 3809-4a - Surface Management Personal Bond Rider Page 2
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1
2NOTE
This coverage of obligations will continue whether or not a notice/plan of operations has subsequently been suspended or terminated. This
rider will not act to increase the actual cumulative or potential liability of the principal or bond above the face amount of the bond. Nothing
herein contained will vary, alter, or extend any provision or condition of this bond except as herein expressly stated.
:
day of
Executed this
, 20
(Principal)
(TIN or SSN, if applicable)
(By)
(Title)
(Business Address)
State of
County of
Subscribed and sworn to before me this
by
(Notary Public)
(My Commission Expires)
NOTICES
THE PRIVACY ACT OF 1974 and the regulation in 43 CFR 2.48(d) require that you be furnished the following information in
connection with information required by this application.
AUTHORITY: 30 U.S.C. 22 et seq.; 43 U.S.C. 1732(b) and 1782(c); 31 U.S.C. 9301 et seq.; 43 CFR 3802 and 3809.
PRINCIPAL PURPOSE: Information is being used to establish financial responsibility for surface disturbance on public lands.
ROUTINE USES: BLM will only disclose the information according to the regulations at 43 CFR 2.56(d).
EFFECT OF NOT PROVIDING INFORMATION: Disclosure of the information is necessary to obtain or retain a benefit. Failure to
disclose this information may result in BLM’s rejection of your application.
THE PAPERWORK REDUCTION ACT OF 1995 requires us to inform you that:
The BLM collects this information to grant the right to conduct exploration and mining activities on public lands.
Response to this request is required to obtain or retain a benefit.
The BLM would like you to know that 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 8 hours per response, including the
time for reviewing instructions, gathering and maintaining data, and completing and reviewing the form. Direct comments regarding the
burden estimate or any other aspect of this form to U.S. Department of the Interior, Bureau of Land Management (1004-0194), Bureau
Information Collection Clearance Officer (WO-630), 1849 C Street, N.W., Room 2134LM,Washington, D.C. 20240.
(Form 3809-4a, page 2)
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