Form MMS-4435 Administrative Appeal Bond

U.S. Department of the Interior
Minerals Management Service
Minerals Revenue Management

OMB Control Number 1010-0122
OMB Approval Expires July 31, 2008

ADMINISTRATIVE APPEAL BOND
Form MMS-4435
Bond No. __________________

Bond Amount $_____________________
Date Bond Executed _________________

KNOW ALL MEN BY THESE PRESENTS, That we, _____________________________ as Principal, and
________________________, a corporation duly organized and existing under the laws of the State of
______________________, having its principle office at ________________________________________, as
Surety are held and firmly bound unto the United States Minerals Management Service in the sum of
$____________________, for the payment of which sum well and truly to be made, we bind ourselves, and our
heirs, executors, administrators, jointly and severally, firmly by these presents.
THE CONDITION OF THIS OBLIGATION IS SUCH THAT, WHEREAS, the bond is intended to secure the
payment of royalties and interest due the United States Minerals Management Service in the event that
__________________________ is unsuccessful in its administrative appeal to the Director, Minerals
Management Service, of (Bill Number(s))_____________________________, dated ________________, or
any order (invoice) which may be substituted, if__________________ shall pay all royalties and interest found
to be due under the decision on that appeal within the time required therefor, this instrument shall be of no force
or effect; otherwise, it will remain in full force and effect.
Principal

Surety

_________________________________
(Legal Name)
_________________________________
(Address)
_________________________________

_________________________________
(Legal Name)
_________________________________
(Address)
_________________________________

By_______________________________

_________________________________

Its ______________________________

_________________________________

Corporate Seal (where required)

Paperwork Reduction Act of 1995 (PRA) Statement: The PRA (44 U.S.C. § 3501 et seq.) requires us to inform you that we collect
this information to allow lessees, designees, or payors to stay the effectiveness of an order or decision by posting a surety instrument.
The MMS uses the information to secure the financial interests of the public and Indian lessors during the entire administrative and
judicial appeal process. Responses are required to obtain a benefit (43 U.S.C. § 1334). Proprietary information is protected in
accordance with standards established by the Federal Oil and Gas Royalty Management Act of 1982 (30 U.S.C. § 1733), the Freedom of
Information Act (5 U.S.C. § 552(b)(4)), the Department regulations (43 CFR § 2). An agency may not conduct or sponsor, and a person
is not required to respond to, a collection of information unless it displays a currently valid OMB Control Number. Public reporting
burden for this form is estimated to average 1 hour 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 the Information Collection Clearance Officer, Minerals Management Service, Mail Stop 4230, 1849 C Street, NW, Washington,
DC 20240.

Form MMS-4435 (revised 02/2005)