Form 3830-4 - Affidavit Of Annual Assessment Work Page 3
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4markings sufficient to appropriately designate the corner of the claim to which it pertains and the name of the
claim(s).
I hereby certify under penalty of perjury under the laws of the State of
___________________
that the
foregoing statements are true and correct:
_____________________________________________________
_ Date:
____________________________
(Signature of person responsible for above statement)
Title 18 U.S.C. 1001 and 43 U.S.C. 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.
Notary Block
SUBSCRIBED AND SWORN TO before me, this
__________
_ day of
____________________
20
________
By:
_________________________________________________________
(Signature of Affiant)
Title:
________________________________________________________
My Commission Expires:
______________________ __
_
_______________
INSTRUCTIONS
1. This is an optional form that may be used to satisfy the requirements for the Bureau of Land Management (BLM)
under the provisions of 43 U.S.C. §1744 and 30 U.S.C. §28-28d and the regulations thereunder (43 CFR part
3835). Since local and State laws may vary, you should contact your local and State agencies where the claims
are located to ensure all applicable laws and requirements are satisfied.
2. The claimant(s) must fill in the date in paragraph 1 for the applicable assessment year and the county and state
where the claims are located.
3. All claim names, BLM serial numbers, legal descriptions, and original county recording information must be
listed for the claims pertaining to this assessment notice.
4. The claimant(s) must complete paragraph 2 listing all labor or improvements which was performed on or did
benefit the subject mining claims. The value and date of the labor or improvements must also be listed. The total
amount of labor or improvements can be listed, but the total expenditure must equal at least $100 for each claim.
5. The names and current mailing addresses of the person(s) performing the labor shall be listed in paragraph 3.
6. The name and current mailing address of each owner (claimant) of the claims shall be listed in paragraph 4. The
mailing address shall be the owner’s address and not the address of an agent or anyone representing the claimant.
Be sure to note if there has been a change of address.
7. Paragraph 5 shall be completed to show the date it was verified that all monuments required by law were properly
erected, all notices were posted, and that corners were appropriately designated for all claims listed.
8. An exact legible reproduction or duplicate (other than microfilm or other electronic media) of this affidavit or
another type of affidavit of assessment work that you file or will file in the county where each claim is located,
must be filed with the BLM on or before December 30 of the calendar year in which the assessment year ends.
For mill or tunnel sites, a separate notice of intent to hold must be filed with the BLM on or before December 30.
Requirements for filing a notice of intent to hold can be found at 43 CFR 3835.33.
A processing fee of $10 for each claim listed must be remitted to the BLM along with this or any other affidavit
9.
of assessment work
.
_______________________________________________________________________________________________________________________________________
(Continued on page 4)
( Form 3830-4, page 3)
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