Form 3830-2 Maintenance Fee Payment Waiver Certification

Form 3830-2
(January 2004)

UNITED STATES DEPARTMENT OF THE INTERIOR
BUREAU OF LAND MANAGEMENT

MAINTENANCE FEE WAIVER CERTIFICATION

FORM APPROVED
OMB NO. 1004-0114
Expires: December 31, 2006

SEE INSTRUCTIONS ON REVERSE
and ending at noon on September 1,
.
1. This small miner waiver is filed for the assessment year beginning at noon on September 1,
2. The undersigned and all related parties owned ten or fewer mining claims, mill, or tunnel sites located and maintained on Federal lands in the United
States of America on September 1,
.
3. The undersigned have performed the assessment work required by law for each mining claim listed prior to filing this waiver and understand that by
filing this form; an affidavit of assessment work must be recorded by the December 30th following the filing of this waiver.
4. The undersigned understand that if the assessment work obligation has not yet come due under 30 U.S.C. 28 (for those claims in their first assessment
year only); a notice of intent to hold reciting this condition must be recorded by the December 30th following the filing of this waiver.
5. The undersigned understand that mill and tunnel sites may also be listed upon this waiver and be waived from payment of the maintenance fee; and that
a notice of intent to hold for these sites is required to be recorded by the December 30th immediately following the filing of this waiver.
6. The undersigned understand and acknowledge that pursuant to 43 U.S.C. 1212 and 18 U.S.C. 1001; the filing or recording of a false, fictitious, or
fraudulent document with the Bureau of Land Management may result in a fine of up to $250,000, a prison term not to exceed five years, or both.
7. The mining claims, mill or tunnel sites for which this waiver from payment of the maintenance fees is requested are:
CLAIM OR SITE NAME

BLM RECORDATION SERIAL NUMBER

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
The owner(s) (claimants) of the above mining claims and sites are:
(Owner's Name - Please Print)

(Owner's Signature)

(Street or P.O. Box)
(City)

(State)

(Zip Code)

(Owner's Name - Please Print)

(Owner's Signature)

(Street or P.O. Box)
(City)

(State)

(Zip Code)

(Owner's Name - Please Print)

(Owner's Signature)

(Street or P.O. Box)
(City)
(Continued on page 2)

(State)

(Zip Code)

(Owner's Name - Please Print)

(Owner's Signature)

(Street or P.O. Box)

(City)

(State)

(Zip Code)

(Owner's Signature)

(Owner's Name - Please Print)
(Street or P.O. Box)

(City)

(State)

(Zip Code)

(Owner's Signature)

(Owner's Name - Please Print)
(Street or P.O. Box)

(City)

(State)

(Zip Code)

(Owner's Signature)

(Owner's Name - Please Print)
(Street or P.O. Box)

(City)

(State)

(Zip Code)

INSTRUCTIONS
1. This certification is made under the provisions of § 1744 of Title 43 and § 287. This form must be filed no later than September 1st for the upcoming
28k of Title 30 of the United States Code; and the regulations thereunder (43
assessment year in the BLM State Office where the mining claims or sites are
CFR Part 3830).
recorded, or the waiver cannot be granted by the BLM. (Example: to obtain a
waiver for the assessment year 2000, which begins at noon on September 1,
2. The claimant(s) must fill in the dates in paragraph 1 for the beginning and
1999, you must qualify for and file for a waiver no later than September 1,
ending of the assessment year for which this waiver is sought.
1999, in the proper BLM State Office).
3. The claimant(s) must fill in the date in paragraph 2 for the beginning of the
assessment year for which this waiver is sought.
8. For all mining claims which require assessment work, you must record an
affidavit of labor on or before the December 30th immediately following the
4. All claim and site names and Bureau of Land Management (BLM) serial
filing of this waiver. For all other mining claims or sites waived, you must
numbers must be listed for the mining claims, mill sites, and tunnel sites for
record a notice of intent to hold on or before the December 30th immediately
which the waiver is sought.
following the filing of this waiver.
5. All owners of the mining claims, mill sites, and tunnel sites and their
addresses must be given.
9. Mill and tunnel sites may also be listed upon this waiver and be waived from
6. This waiver form must be signed by all the claimants or their designated
payment of the maintenance fee. A notice of intent to hold for these sites is
agent, in original form. If an agent is designated, a notarized designation of
required to be filed by the December 30th following the filing of this waiver.
agent, signed by all of the claimants with proper address given, must be
submitted with this waiver.
NOTICE/BURDEN HOURS STATEMENT
The Privacy Act of 1974, as amended, and the regulation in 43 CFR 2.48(d)
provide that you be furnished the following information in connection with the
information required by this certification of waiver from rental fees.

AUTHORITY: 30 U.S.C. 28-28k; 43 U.S.C. 1201, 1457, 1740, and 1744; and 43
CFR 3830.
PRINCIPLE PURPOSE: This information is to be used to verify that the
owner(s) (claimants) of a mining claim has complied with 30 U.S.C. 28f and is
entitled to perform assessment work in lieu of paying the maintenance fee for the
mining claims listed on this form.
ROUTINE USE: (1) Adjudication of the claimant(s) certification of waiver from
paying the maintenance fee otherwise required by 30 U.S.C. 28f. (2) Disclosure
may be made to appropriate Federal agencies when location is made within the
agency's geographic area of responsibility. (3) Information from the record and/or
the record will be transferred to the appropriate Federal, State, or local agency, or a
member of the public in response to a specific request for pertinent information.
(4) Information may also be provided to the Department of Justice or in a
proceeding before a court or adjudicative body; or to Federal, State, local or
foreign agencies when needed for enforcement of civil or criminal codes or
applicable regulations concerning title rights upon the public land.

The Paperwork Reduction Act of 1995 requires us to inform you that:
This information is being collected to allow the BLM to determine if you qualify
for a waiver from the payment of $100 per mining claim or site maintenance fee
established in 30 U.S.C. 28f and the implementing regulations at 43 CFR 3830. A
response to this request is required in accordance with the statute to obtain your
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.
Public reporting burden for this form is estimated to average 8 minutes (0.133
hours) per response, including time to review instructions, gathering and
maintaining data, and completing and reviewing the form. Direct comments
regarding this burden estimate, or any other aspect of this form, to the U.S.
Department of the Interior, Bureau of Land Management, (1004-0114) Bureau
Information Collection Clearance Officer (WO-630), Mail Stop 401 LS, 1849 C
St., N.W.,Washington, D.C. 20240.

FOR OFFICIAL USE ONLY

EFFECT OF NOT PROVIDING INFORMATION: Disclosure of this
information is required by 30 U.S.C. 28f and 43 CFR Part 3830 for those qualified
claimants wishing to take the small miner waiver allowed. Failure to supply the
information required in this form to support the claimants certification of waiver
from payment of the otherwise required maintenance fees will result in the waiver
being disallowed and the mining claims subject to forfeiture by BLM under 30
U.S.C. 28i.

(Form 3830-2, page 2)