3504-4 Statewide or Nationwide Mineral Bond

NOTICES
The Privacy Act of 1974 and the regulation, in 43 CFR 2.48(d) provide that you be furnished with the following
information in connection with information required by this bond form.
AUTHORITY: 30 U.S.C. 181 et seq; 43 U.S.C. 3500
PRINCIPAL PURPOSE: BLM will use the information you provide to ensure that the United States is fully
indemnified against failure to perform under the terms, conditions, and stipulations of a mineral lease on all your
leases held within a state or nationwide.
ROUTINE USES: BLM will disclose information to: (1) Appropriate Federal, State, local or foreign agencies, when
relevant to civil, criminal, or regulatory investigations or prosecutions; (2) appropriate Federal agencies when their
concurrence is required before BLM grants a right in public lands or resources: (3) a member of the public in
response to a specific request for pertinent information; (4) a congressional office in response to an inquiry made at
the the request of an individual; and (5) to a consumer reporting agency to expedite collecting debts owed the
government.
EFFECT OF NOT PROVIDING INFORMATION: Filing of this information is required to obtain and keep a
benefit. If you do not provide a bond, BLM will not issue you a mineral lease.
The Paperwork Reduction Act of 1995 requires us to inform you that:
BLM collects this information to comply with the regulations at 43 CFR 3500, which implement the provisions of
the Mineral Leasing Act of 1920, as amended; the Mineral Leasing Act for Acquired Land of 1947; and section 402
of Reorganization Plan No. 3 of 1946.
BLM uses the information to protect the interests of the United States in cases where lessees fail to perform under
the terms, conditions, and stipulations of their mineral leases or permits.
Response to this request is required to obtain and keep a benefit.
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 4 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 (1004-0121), Bureau Information Collection Clearance
Officer (WO-630), 1849 C Street, N.W., Mail Stop 401 LS, Washington, D.C. 20240.

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(BLM Form 3504-4, page 3)