Form 3830 4 – Fill Out and Use This PDF

markings 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: ____________________________

ytrolkcaNB(Signature of person responsible for above statement)

Title 18 U.S.C. 1001 and 43 U.S.C. 1212 make it 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: ________________________________________________________

MyyxutsrponmlkCommission 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 addｕｈｖｖ＃ｖｋｄｏｏ＃ｅｈ＃ｗｋｈ＃ｒｚｑｈｕﾶｖ＃ｄｇｇｕｈｖｖ＃ｄｑｇ＃ｑｒｗ＃ｗｋｈ＃ｄｇｇｕｈｖｖ＃ｒｉ＃ｄｑ＃ｄｊｈｑｗ＃ｒｕ＃ｄｑ｜ｒｑｈ＃ｕｈｓｕｈｖｈｑｗｌｑｊ＃ｗｋｈ＃ｆｏｄｌｐｄｑｗ１＃＃

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.

9.A processing fee of $10 for each claim listed must be remitted to the BLM along with this or any other affidavit of assessment work.

_______________________________________________________________________________________________________________________________________

(Continued on page 4)	( Form 3830-4, page 3)
county form

yxutsrponmDO NOT RECORD THIS PAGE

NOTICES

THE PRIVACY ACT and 43 CFR 2.48(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 2.56(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 ＥＯＰﾶｖ＃ｓｕｒｆｈｖｖｌｑｊ＃ｒｉ＃ｗｋｈ＃ｉｒｕｐ＃ｄｑｇ＃ｐｄ｜＃ｓｕｈｆｏｘｇｈ＃ｗｋｈ＃ＥＯＰﾶｖ＃ｄｆｆｈｓｗｄｑｆｈ＃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). Submission of the requested information is necessary to obtain or

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 minutes per 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)