Form 3809-4 Bond Rider Extending Coverage of Bond to Assume Liabilit

Form 3809-4
(January 2004)

FORM APPROVED
OMB NO. 1004-0194
Expires: January 31, 2007

UNITED STATES
DEPARTMENT OF THE INTERIOR
BUREAU OF LAND MANAGEMENT

BLM Bond Number

Form for Bond Rider Extending Coverage of Bond to Assume Liabilities for
Operations Conducted by Parties Other Than the Principal
(Consent of Surety)
RIDER

Surety Bond Number, if applicable

The principal and surety (or principal/obligor, if a personal bond) hereby agree to extend the coverage of the bond referenced above to include liabilities
for operations conducted by

on
(Name of Mine/Operation)

plan/notice serial number

in which the principal holds interest or in the

State of

(Statewide bond) or Nationwide (Nationwide bond).

Coverage includes the faithful performance of all plan of operations or notice level operations, both past and future, including the responsibility for all
surface reclamation, as filed or approved by the Bureau of Land Management (BLM).
This coverage of plan of operations or notice level operations, will continue whether or not the plan(s) and/or notice(s) subsequently expire, terminate, are
abandoned, suspended or revoked; provided however, that this rider will not act to increase the actual cumulative or potential liability for the surety above
the face amount of the bond (penal sum).
Executed this

day of

, 20

Principal

.

Surety

By
(Print Name)

By

Signature
Attorney-in-Fact
(Print Name)

Title

Business Address

Business Address

(TIN or SSN, if applicable)

(TIN or SSN)

This bond must bear the seal of the surety company, if a surety bond. If this bond is signed by a corporation, it should bear the
seal of the corporation, if applicable.
NOTICE
The Privacy Act of 1974 and the regulation in 43 CFR 2.48(d) provide that you be furnished the following information in connection with information
required by this application.
AUTHORITY: 30 U.S.C. 22 et seq.; 43 U.S.C. 1732[b] and 1782[c]; 31 U.S.C. 9301 et seq.; 43 CFR 3802 and 43 CFR 3809.
PRINCIPAL PURPOSE: Information is being used to establish financial responsibility for surface disturbance on public lands.
ROUTINE USES: BLM will only disclose the information according to the regulations at 43 CFR 2.56(d).
EFFECT OF NOT PROVIDING INFORMATION: Disclosure of the information is necessary to receive a benefit. Failure to disclose this information
may result in BLM’s rejection of your application.
The Paperwork Reduction Act of 1995 requires us to inform you that:
BLM collects this information to grant the right to conduct exploration and mining activities on public lands.
Response to this request is required to obtain 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 8 minutes 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 (1004-0194), Bureau Information Collection Clearance Officer (WO-630), 1849 C Street, N.W.,
Washington, D.C. 20240
Title 18 U.S.C. Section 1001 and Title 43 U.S.C. Section 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.