FORM APPROVED OMB
DEPARTMENT OF THE INTERIOR
No. 1004-0194 Expires:
BUREAU OF LAND MANAGEMENT
January 31, 2020
BLM Bond Number
Form for Bond Rider Extending Coverage of Bond to Assume Liabilities for
Operations Conducted by Parties Other Than the Principal
Surety Bond Number
(Consent of Surety)
The principal and surety (or principal/obligor, if a personal bond) hereby agree to extend the coverage of the bond referenced above to include liabilities
for operations conducted by
(Name of Mine/Operation).
plan/notice serial number
in which the principal holds interest or in the
(Statewide bond) or Nationwide (Nationwide bond).
Coverage includes the faithful performance of all plan of operations or notice level operations, both past and future, including the
responsibility for all surface reclamation, as filed or approved by the Bureau of Land Management (BLM).
This coverage of plan of operations or notice level operations, will continue whether or not the plan(s) and/or notice(s) subsequently
expire, terminate, are abandoned, suspended or revoked; provided however, that this rider will not act to increase the actual cumulative
or potential liability for the surety above the face amount of the bond (penal sum).
(TIN or SSN, if applicable)
(TIN or SSN)
This bond must bear the seal of the surety company, if a surety bond. If this bond is signed by a corporation, it should bear the seal
of the corporation, if applicable.
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 department or agency of the
United States any false fictitious, or fraudulent statements or representations as to any matter within its jurisdiction.
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.