Application for Self-Bond

United States Department of the Interior

OFFICE OF SURFACE MINING RECLAMATION AND ENFORCEMENT

APPLICATION FOR SELF-BOND

Attach additional page(s) as needed and reference the application form item number to which addition(s) apply. Financial data must be in U.S. Currency. NOTE: if the Parent Company of the Permittee is applying for Self-Bonding as a corporate Guarantor, the Guarantor must respond to all items on the application as the Applicant. If a non-parent corporation is applying as Guarantor under this application, the Guarantor must address all items on the application form and the Permittee must also complete an additional application to address all items except Item 7.

1. Identification of Permittee: _______________________________________ Permit No. _________

2. Identification of Applicant/Guarantor and Guarantor’s relationship to Permittee: _____________

________________________________________________________________________________

3. Type of Entity Applying for Self-bonding or Applying as Guarantor: ________________________ (i.e., Corporation, LLC, Joint Venture, Limited Partnership, Partnership, etc.)

(a) Corporations:

Address: _________________________________________________

Telephone No.: ____________________________________________

State of Incorporation: ______________________________________

Principal Place of Business: __________________________________

Name, Title and Authority of person signing this application: ____________________

_____________________________________________________________________

Certification of Authority to do business in (State where operation located):_________

_____________________________________________________________________

(b) OTHER forms of business enterprises:

Address: ________________________________________________________

Telephone: ______________________________________________________

State of Formation: ________________________________________________

Principal Place of Business: _________________________________________

Name, Title and Authority of person signing this application: ______________________

_______________________________________________________________________

4. (a) Amount of Bond required in accordance with 30 CFR §800.14: $____________________ _______________________________________________________________________

(b) ^**Amount which is proposed to be under a self-bond: _____________________________ ________________________________________________________________________.

(c) Amount of this proposed self-bond plus all of your other outstanding, proposed, and guaranteed self-bonds for coal mining operations in the United States: $__________

____________________________________________________________________

(d) Tangible Net Worth in the United States: $__________________________________

5. A brief description and chronological history of those business operations of the applicant conducted within the last five (5) years that would demonstrate a continuous operation. If the applicant is a joint venture with less than five (5) years, describe the chronological history and business operations of the individual joint ventures. List any past periods of interruption of the business operation and the reasons for such interruption.

6. Attach audited financial statements in conformance with U.S. Generally Accepted Accounting Principles (GAAP) to include:

(a) Applicant’s Balance Sheet for the most recently completed fiscal year.

(b) Applicant’s Income Statement for the most recently completed fiscal year.

(c) A report for the most recently completed fiscal year containing the audit or review opinion of the audited financial statements with no adverse opinion by an independent certified public accountant.

(d) Un-audited financial statements for all completed quarters in the current fiscal year.

7. Indicate under which of the three criteria at 30 CFR §800.23(b)(3) the applicant is applying to qualify for self-bonding:

30 CFR §800.23(b)(3)(i)___________________________________________________________; or

30 CFR §800.23(b)(3)(ii)___________________________________________________________; or

30 CFR §800.23(b)(3)(iii)___________________________________________________________.

(i) If applying on the basis of the financial test at 30 CFR§ 800.23(b)(3)(i), provide the following information:

a. Current bond rating of the most recent bond issuance of the applicant:________________

b. Name of rating service: _____________________________________________________

(Attach the bond rating service’s written confirmation of current bond rating.)

c. Date of issuance of the bond: ________________________________________________

d. Date of maturity of the bond: ________________________________________________

(ii) If applying on the basis of the financial test at 30 CFR §800.23(b)(3)(ii), provide the following information:

a. Tangible net worth: $_____________________________________________________

b. Ratio of Current Assets to Current Liabilities: _________________________________

c. Ratio of Total Liabilities to Net Worth: _______________________________________

(iii) If applying on the basis of the financial test at 30 CFR §800.23(b)(3)(iii), provide the following information:

a. Fixed Assets in the United States (excluding land and coal in place):$_______________

b. Ratio of Current Assets to Current Liabilities: __________________________________

c. Ratio of Total Liabilities to Net Worth: ________________________________________

8. Registered agent for service of process (in the State where the permittee’s operation is located):

Name⁺:_____________________________________________________________________

Address: ____________________________________________________________________

Telephone Number:____________________________________________________________

OSM will notify the permittee in writing of its determination as to whether the applicant qualifies for self-bonding and whether OSM approves the self-bond. If approved for self-bonding, OSM will assign a Self-Bond Number. Using this assigned number, several self-bonding documents must be executed by the permittee and/or the Guarantor and approved by OSM. These documents include a Self-Bond Agreement (Permittee); an Indemnity Agreement (Permittee and Guarantor) and a Corporate Guarantee (parent Guarantor) or Non-Parent Corporate Guarantee, as applicable.

Provide the names and addresses of individuals who are to receive notice and the above forms from OSM:

For the Permittee: ____________________________________________________________________

For the Guarantor: ____________________________________________________________________

NOTES:

** This plus all other outstanding and proposed self-bonds may not exceed 25% of an applicant’s tangible net worth in the United States.

+ Any change in the registered agent must be filed immediately with OSM.

State of ________________________)

) SS

County of ______________________)

I_________________________________(please print or type) am the applicant for the foregoing application to self-bond; I have read the application and fully know the contents thereof; and all statements contained in the application to self-bond are true and correct to my best knowledge and belief.

Dated and signed this __________ day of __________________________, ______.

BY: _____________________________

(Corporate Seal) TITLE: ___________________________

(please print or type)

State of ________________________)

) SS

County of ______________________)

The foregoing instrument was acknowledged before me by ____________________________________

this _____ day of ____________________, ______. (Name of Principal Signatory - please print or type)

Witness my hand and official seal. ____________________________________

(Notary Public or other Authorized Officer)

____________________________________

(Title) (Name printed or typed)

My Commission Expires: ________________

Paperwork Reduction Act Notice

We use the information required by this form to determine whether a person qualifies for a self-bond under 30 CFR 800.23. You must provide the requested information to obtain a benefit (a self-bond). Under 30 CFR 842.16, the information collected is a matter of public record.

The time needed to complete this form and submit the requested information will vary depending on individual circumstances. We estimate that the average time will be 16 hours per response. This number includes the time spent reviewing instructions, learning about the regulations, gathering and maintaining information, and completing and reviewing the form. If you have comments concerning the accuracy of this estimate or suggestions for simplifying the form or instructions, you may write to the Information Collection Clearance Officer, Office of Surface Mining Reclamation and Enforcement, Room 202 SIB, 1951 Constitution Ave, NW, Washington, D.C. 20240.

Under the Paperwork Reduction Act of 1995 (44 U.S.C. 3501 et seq.), you are not required to respond to, nor will you be subject to a penalty for a failure to comply with, a collection of information unless it displays a currently valid OMB control number.

OMB Control No. 1029-0043, expires 9/30/2015

Permit No.____________ Page 4 of 4 Self Bond Application