Form 3830-4 - Affidavit Of Annual Assessment Work Page 2
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42. Type of labor and improvements (specify what was done and give the total value for that labor and
improvement to show at least $100 for each claim). If a geological, geochemical, or geophysical survey was
performed, as per 30 U.S.C. 28-1, reference the title of the report of survey, give cost and date of the survey
and report, and indicate it was filed with the County Recorder:
Value of Work
Date Work Was
Description of Work Performed
Performed
Performed
3. Name and mailing address of each person who performed the labor and improvements:
Name (please print)
Current Mailing Address (please print)
______________________________
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4. Name and mailing address of each person who holds and claims the subject mining claim(s) for the valuable
minerals contained therein. Be sure to indicate if there is a change of address:
Name (please print)
Current Mailing Address (please print)
______________________________
______________________________________________________
______________________________
______________________________________________________
______________________________
______________________________________________________
______________________________
______________________________________________________
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5. The undersigned testifies that on the date of
__________________________,
20___, all monuments
required by law were erected upon the subject claim(s), and all notices required by law were posted on the
subject claim(s) or copies thereof were in place, and at said date, each corner monument bore or contained
_______________________________________________________________________________________________________________________________________
(Continued on page 3)
( Form 3830-4, page 2)
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