Fillable Form 3809-2 - Surface Management Personal Bond (Page 2 of 2) in pdf

Form 3809-2 - Surface Management Personal Bond Page 2

Download a blank fillable Form 3809-2 - Surface Management Personal Bond in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form 3809-2 - Surface Management Personal Bond with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

, 20

Executed this

day of

Principal

State of

Country of

(Print name)

Subscribed and sworn to before me this

day

Signature

, 20

Title

Business Address

(Notary Public)

(Date Commission Expires)

(TIN or SSN No., 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.

If this bond is executed by a corporation, it should bear the seal of the corporation, if applicable.

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.; CFR 3802 and 43 CFR 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 the 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 about 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 3809-2, page 2)