Powe of Attorney and Agreement for Collateral Bond (Corp

United States Department of the Interior
OFFICE OF SURFACE MINING RECLAMATION AND ENFORCEMENT

POWER OF ATTORNEY AND AGREEMENT FOR COLLATERAL BOND
(Corporation)

KNOW ALL PERSONS BY THESE PRESENTS, that
__________________________________________________________________________,
(Name of Corporation – Permittee)

a corporation duly incorporated under the laws of the State of ________________________, in
pursuance of a resolution of the Board of Directors of said corporation, passed on the _______
day of ___________________, ________, does hereby constitute and appoint
________________________________________________ and his/her successors in office,
(Name and official title of Bond-Approving Officer)

and his/her successors in office, as attorney for said corporation to collect or to sell, assign and
transfer certain securities, certificates of deposit or other instruments described as follows:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
such negotiable securities having been deposited by it, as security for the faithful performance of
any and all of the conditions or stipulations of a certain obligation entered into by it with the
United States, under date of _______________________, with respect to Permit No. _________,
(Date Collateral Bond Signed)

which is hereby made a part hereof, and the undersigned agrees that, in case of any default in the
performance of any of the conditions and stipulations of such undertaking, its said attorney shall
have full power to collect said securities or any part thereof, or to sell, assign, and transfer said
securities or any part thereof without notice, at public or private sale, free from any equity of
redemption and without appraisement or valuation, notice and right to redeem being waived, and
to apply the proceeds of such sale or collection, in whole or in part, to the satisfaction of any
damages, demands, or deficiency arising by reason of such default, as its said attorney may deem
best; and the undersigned further agrees that the authority herein granted is irrevocable.
And said corporation for itself, its successors and assigns, ratifies and confirms whatever its said
attorney shall do by virtue of these presents.

Permit No._____________

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Power of Attorney & Agreement (Corp)

IN WITNESS WHEREOF, the Obligor has hereunto set its signature this _________ day of
____________, ______.
_____________________________________
(Corporation – Permittee)

By:__________________________________________
(Corporate Officer)

Title:_____________________________________

ACKNOWLEDGEMENT

On this ______ day of ____________________,________, before me, a Notary Public in
and for the County of _______________________, in the State of ________________________,
appeared _______________________________ to me personally known who, being by me duly
sworn, did say that he/she is _________________________ of __________________________,
the corporation named in and which executed the within instrument, and that the seal affixed to
said instrument is the corporation seal of said corporation, and that said instrument was signed,
sealed, and delivered in behalf of said corporation by authority of the Board of Directors, and
he/she, as such officer, acknowledged said instrument to be the free act and deed of said
corporation for the uses and purposes of said instrument as therein set forth.
IN WITNESS WHEREOF, I have hereunto set my hand and official seal on the day,
month, and year aforesaid.
My Commission Expires: ________________________________________________
(Notary Public in aforesaid County and State)

NOTE: Securities must be described by issuing institution, title, date of maturity, rate of interest,
denomination, serial number, and whether coupon or registered.

Paperwork Reduction Act Notice
We use the information required by this form to ensure that the requirements for a collateral bond under 30 CFR
800.21 have been met. You must provide the requested information to obtain a benefit (a collateral bond). Under
30 CFR 842.16, the information collected is a matter of public record.
The time needed to complete this form and related forms and submit the requested information to obtain a collateral
bond will vary depending on individual circumstances. We estimate that the average time will be 10 hours per
response. This number includes the time spent reviewing instructions, learning about the regulations, gathering and
maintaining information, and completing and reviewing the forms. If you have comments concerning the accuracy
of this estimate or suggestions for simplifying the forms 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 7/31/2012

Permit No._____________

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Power of Attorney & Agreement (Corp)