Form 3830-4 - Affidavit Of Annual Assessment Work Page 4
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4NOTICES
THE PRIVACY ACT and 43 CFR 2.223(d) require that you be furnished with the following information in
connection with the information requested by this form.
AUTHORITY: 30 U.S.C. §28-28d and 43 CFR part 3835 permit collection of the information requested by
this form.
PRINCIPAL PURPOSE: The BLM will use the information you provide to document compliance with 43
U.S.C. 1744 and that assessment work has been completed in accordance with 30 U.S.C. § 28-28d and 43 CFR
part 3835 in lieu of paying the maintenance fee for the mining claims listed on this form.
ROUTINE USES: The BLM will only disclose this information in accordance with the provisions at 43 CFR
2.231(b) and (c).
EFFECT OF NOT PROVIDING INFORMATION: Disclosure of the requested information is required by
30 U.S.C. § 28-28d and 43 CFR part 3835 for claimants qualified to perform assessment work in lieu of paying
the maintenance fee. Failure to submit all the requested information or to complete this form will delay the
BLM’s processing of the form and may preclude the BLM’s acceptance of the assessment work information,
which may result in forfeiture of the mining claim(s) by the claimant.
THE PAPERWORK REDUCTION ACT requires us to inform you that:
Use of this form is optional. You must perform assessment if a waiver to pay the maintenance fee has been
requested. This form is provided to help you attest that annual assessment work has been completed in lieu of
paying the maintenance fee for your claim(s).
ubmission of the requested information is necessary
to obtain or
S
retain a benefit.
You do not have to respond to this or any other Federal agency-sponsored information collection unless it
displays a valid OMB control number.
BURDEN HOURS STATEMENT: The estimated public reporting burden for this form is 30
per
minutes
response, including the time for reviewing instructions, gathering and maintaining data, and completing and
reviewing the form. You may submit comments regarding the burden estimate or any other aspect of this form
to: U.S. Department of the Interior, Bureau of Land Management (1004-0114), Bureau Information Collection
Clearance Officer (WO-630), 1849 C Street, N.W., Room 2134LM, Washington, D.C. 20240.
_______________________________________________________________________________________________________________________________________
(Form 3830-4, page 4)
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