3504-4 Statewide or Nationwide Mineral Bond

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UNITED STATES
DEPARTMENT OF THE INTERIOR
BUREAU OF LAND MANAGEMENT

Form 3504-4
(October 2007)

FORM APPROVED
OMB NO. 1004–0121
Expires: November 30, 2009

STATEWIDE OR NATIONWIDE PERSONAL MINERAL BOND
FOR
PROSPECTING PERMITS AND LEASES
COAL, SODIUM, PHOSPHATE, POTASSIUM, SULPHUR, AND OTHER MINERAL DEPOSITS

Know All Men By These Presents, That

of

,

as obligor, is held and firmly bound unto the United States in the sum of

dollars ($
), lawful money of the United States, to be paid
to the United States, for the use and benefit of (1) the United States and (2) any owner of a portion of the land subject to the coverage of
this bond, who has a statutory right to compensation in connection with a reservation of the above-mentioned deposits to the United States.
For such payment, well and truly to be made, he binds himself, his heirs, executors, administrators, and successors, jointly and severally,
by these presents.
That said Obligor, in order to more fully secure the United States in the payment of the aforesaid sum, hereby pledges as security
therefor bonds of the United States, of a par value equal to the amount specified, which said bonds are numbered serially and are in
the demoninations and amounts and are otherwise more particularly described as follows:
Bonds of $

, Bearing

percent interest, with

coupons attached to each, numbered

which said bonds have been deposited with the Secretary of the Interior.
If amount of this bond is $75,000, or if it is raised by an attached rider to that amount, coverage must extend to all obligor’s holdings
involving
deposits in the United States, including Alaska, under the act or acts cited in Schedule A.
If amount of this bond is $25,000, its coverage extends only to obligor’s holdings involving
deposits in the State named under the act or acts cited in Schedule A.

SCHEDULE A
Public Domain Leasing Act of February 25, 1920
(30 U.S.C. Sec. 181)

Acquired Lands Leasing Act of August 7, 1947
(30 U.S.C. Sec. 351)

Names of States

Names of States

That conditions of the foregoing obligations are such that, whereas the
said obligor, in one or more of the following ways, has an interest in
mineral permits or leases issued under the act or acts cited in Schedule
A of this bond:

1. as permittee or as lessee;

2. as the approved holder of operating rights in all or part of the
lands covered by permits or leases under operating agreements with the
lessees; and
(Continued on page 2)

3. as designated operator or agent under permits or leases pending
approval of an assignment or operating agreement; and
Whereas the obligor is authorized to drill for, mine, extract, remove,
and dispose of the named mineral deposits in or under the lands covered
by the permits, leases, operating agreements or designations, and is
obligated to comply with certain convenants and agreements set forth
in such instruments; and

Whereas the obligor agrees that the coverage of this bond, in addition
to the present holdings of the obligor must extend to and include:

1. Any mineral permit or lease hereafter issued to, or acquired by,
the obligor affecting the named mineral deposits in the State or States
now named in Schedule A, or later named in a rider, the coverage to
be confined in the obligor’s holdings under the act or acts cited at the
head of the column in which the name(s) of the State or States appears
and to become effective immediately upon such issuance or upon
departmental approval of a transfer in favor of the obligor.

2. Any operating agreement hereafter entered into or acquired by
the obligor, affecting the named mineral deposits in the States now
named in Schedule A, or later named in a rider, relating to mineral
permits or leases issued under the act or acts cited in Schedule A at
the head of the column in which the name of the State is placed. The
coverage must become effective immediately upon departmental
approval of the agreement or of a transfer of an operating agreement to
the obligor.

3. Any designation subsequent hereto of the obligor as operator or
agent of a permittee or lessee under a permit or lease issued pursuant to
an act or acts cited in Schedule A and covering lands in a State named
in Schedule A, either presently or by rider. This coverage must become
effective immediately upon the filing of such a designation under a
permit or lease.

4. Any extension of a permit or lease covered by this bond, such
coverage to continue without any interruption due to the expiration of
the term set forth in the permit or lease.
Whereas the obligor hereby agrees that notwithstanding the termination
of any permit or permits, lease or leases, operating agreements or
designations as operator or agent, covered by this bond, whether the
termination is by operation of law or otherwise, the bond must remain
in full force and effect as to any remaining permits, leases, operating
agreements, or designations covered by the bond; and
Whereas the obligor as to any permit or lease or part of a permit or
lease for lands as to which he has been designated as operator or agent,
or approved as operator, in consideration of being permitted to furnish
this bond in lieu of the permittees or lessees, agrees and by these
presents does hereby bind himself to fulfill, on behalf of each permittee
or lessee, all the obligations of each permit or lease for the entire permit
or lease areas in the same manner and to the same extent as though he
were the permittee or lessee; and
Signed on this

day of

(Signature of Witness)

, 20

Whereas the obligor agrees that the neglect or forbearance of the
United States in enforcing, as against the permittees or lessees of the
United States, the payment of rentals or royalties or the performance of
any other convenant, condition, or agreement of the permits or leases,
must not, in any way, release the obligor from any liability under this
bond; and
Whereas the obligor agrees that in the event of any default under the
permits or leases, the United States may commence and prosecute any
claim, suit, action, or other proceeding against the obligor without the
necessity of joining the permittees or lessees.
Now, Therefore, If said obligor must in all respects faithfully
comply with all of the provisions of the permits and leases referred to
hereinbefore, then the above obligations are to be void; otherwise to
remain in full force and effect.
That the said obligor does hereby constitute and appoint the Secretary
of the Interior as his attorney, for him and his name to collect or to sell,
assign, and transfer the said United States bonds above described and
deposited by the obligor, as aforesaid, pursuant to authority conferred
by Section 1 of the act of July 30, 1947 (61 Stat. 646; 6 U.S.C. 15) as
security for the faithful performance of any and all of the conditions
or stipulations as hereinbefore set out, and it is agreed that, in case of
any default in the performance of the conditions and stipulations of
such undertaking the said attorney will have full power to collect said
bonds or any part thereof, or to sell, and transfer said bonds or any part
thereof without notice, at public or private sale, free from any equity
or redemption or without appraisement or valuation, notice and right to
redeem being waived, and to apply proceeds of such sale or collection
to the full amount of the bond to the satisfaction of any damages, or
deficiencies arising by reason of such default, as said attorney may deem
best. The interest accruing upon said United States bonds deposited as
above stated, in the absence of any default in the performance of any of
the conditions or stipulations of the bond, must be paid to said obligor.
The said obligor hereby for himself, his heirs, executors, administrators,
and successors, ratifies and confirms whatever his said attorney will do
by virtue of these presents.

, in the presence of:

(Printed Name of Witness)

(Address of Witness)

(Signature of Witness)

Whereas the obligor agrees that notwithstanding any use of the security
pledged herewith for the purpose for which it is pledged, the bond must
remain in full force and effect in the sum above set forth and that he
will, whenever so required by the United States, deposit additional
security to bring the security up to the full amount; and

(Signature of Obligor)

(Printed Name of Obligor)

(Business Address of Obligor)

(Printed Name of Witness)

[Seal]
(Address of Witness)
If this bond is executed by a corporation, it must bear the seal of such corporation.
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.
(Continued on page 3)

(Form 3504-4, page 2)

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 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.

(BLM Form 3504-4, page 3)