Form 3830-2 Maintenance Fee Waiver Certification

Form 3830-2
(November 2007)

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UNITED STATES
DEPARTMENT OF THE INTERIOR
BUREAU OF LAND MANAGEMENT
MAINTENANCE FEE WAIVER CERTIFICATION

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FORM APPROVED
OMB NO. 1004-0114
Expires: February 28, 2010

SEE INSTRUCTIONS ON PAGE 2
1. This small miner waiver is filed for the assessment year beginning at noon on September 1, _______ and ending at noon on September 1, _______.
2. The undersigned and all related parties owned ten or fewer mining claims, mill, or tunnel sites located and maintained on Federal lands in the
United States of America on September 1, ________.
3. The undersigned have performed the assessment work required by law for each mining claim listed prior to filing this waver and understand that by
filing this form; an affidavit of assessment work must be recorded by the December 30th following the filing of this waiver.
4. The undersigned understand that if the assessment work obligation has not yet come due under 30 U.S.C. 28 (for those claims in their first
assessment year only); a notice of intent to hold reciting this condition must be recorded by the December 30th following the filing of this waiver.
5. The undersigned understand that mill and tunnel sites may also be listed upon this waiver and be waived from payment of the maintenance fee; and
that a notice of intent to hold for these sites is required to be recorded by the December 30th immediately following the filing of this waiver.
6. The undersigned understand and acknowledge that pursuant to 43 U.S.C. 1212 and 18 U.S.C. 1001; the filing or recording of a false, fictitious, or
fraudulent document with the Bureau of Land Management may result in a fine of up to $250,000, a prison term not to exceed five years, or both.
7. The mining claims, mill or tunnel sites for which this waiver from payment of the maintenance fees is requested are:
CLAIM OR SITE NAME

BLM RECORDATION SERIAL NUMBER

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The owner(s) (claimants) of the above mining claims and sites are:
__________________________________________________________
(Owner's Name - Please Print)

__________________________________________________________
(Owner's Signature)

__________________________________________________________
(Street or P.O. Box)
_____________________________ ___________ _________________
(City)
(State)
(Zip Code)
__________________________________________________________
(Owner's Name - Please Print)

__________________________________________________________
(Owner's Signature)

__________________________________________________________
(Street or P.O. Box)
_____________________________ ___________ _________________
(City)
(State)
(Zip Code)
__________________________________________________________
(Owner's Name - Please Print)
__________________________________________________________
(Street or P.O. Box)
_____________________________ ___________ _________________
(City)
(State)
(Zip Code)
(Continued on page 2)

__________________________________________________________
(Owner's Signature)

__________________________________________________________
(Owner's Name - Please Print)

__________________________________________________________
(Owner's Signature)

__________________________________________________________
(Street or P.O. Box)

_________________________________
(City)

__________________________________________________________
(Owner's Name - Please Print)

__________________________________________________________
(Owner's Signature)

__________________________________________________________
(Street or P.O. Box)

_________________________________
(City)

__________________________________________________________
(Owner's Name - Please Print)

__________________________________________________________
(Owner's Signature)

__________________________________________________________
(Street or P.O. Box)

_________________________________
(City)

__________________________________________________________
(Owner's Name - Please Print)

__________________________________________________________
(Owner's Signature)

__________________________________________________________
(Street or P.O. Box)

_________________________________
(City)

_________ ______________
(State)
(Zip Code)

_________ ______________
(State)
(Zip Code)

_________ ______________
(State)
(Zip Code)

_________ ______________
(State)
(Zip Code)

Title 18 U.S.C. Section 1001 and Title 43 U.S.C. Section 1212 makes 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.

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INSTRUCTIONS
This certification is made under the provisions of §1744 of Title 43 and § 28-28k of Title 30 of the United States Code; and the regulations thereunder (43
CFR Part 3830).
The claimant(s) must fill in the dates in paragraph 1 for the beginning and ending of the assessment year for which this waiver is sought.
The claimant(s) must fill in the date in paragraph 2 for the beginning of the assessment year for which this waiver is sought.
All claim and site names and Bureau of Land Management (BLM) serial numbers must be listed for the mining claims, mill sites, and tunnel sites for
which the waiver is sought.
All owners of the mining claims, mill sites, and tunnel sites and their addresses must be given.
This waiver form must be signed by all the claimants or their designated agent, in original form. If an agent is designated, a notarized designation of
agent, signed by all of the claimants with proper address given, must be submitted with this waiver.
This form must be filed no later than September 1st for the upcoming assessment year in the BLM State Office where the mining claims or sites are
recorded, or the waiver cannot be granted by the BLM. (Example: to obtain a waiver for the assessment year 2000, which begins at noon on September 1,
1999, you must qualify for and file for a waiver no later than September 1, 1999, in the proper BLM State Office).
For all mining claims which require assessment work, you must record an affidavit of labor on or before the December 30th immediately following the
filing of this waiver. For all other mining claims or sites waived, you must record a notice of intent to hold on or before the December 30th immediately
following the filing of this waiver.
Mill and tunnel sites may also be listed upon this waiver and be waived from payment of the maintenance fee. A notice of intent to hold for these sites is
required to be filed by the December 30th following the filing of this waiver.

FOR OFFICIAL USE ONLY

(Continued on page 3)

(Form 3830-2, page 2)

NOTICES

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
the information required by this certification of waiver from rental fees.
AUTHORITY: 30 U.S.C. 28-28k; 43 U.S.C. 1201, 1457, 1740, and 1744; and 43 CFR 3830.
PRINCIPLE PURPOSE: This information is to be used to verify that the owner(s) (claimants) of a mining claim has complied with 30
U.S.C. 28f and is entitled to perform assessment work in lieu of paying the maintenance fee for the mining claims listed on this form.
ROUTINE USE: (1) Adjudication of the claimant(s) certification of waiver from paying the maintenance fee otherwise required by 30
U.S.C. 28f. (2) Disclosure may be made to appropriate Federal agencies when location is made within the agency's geographic area of
responsibility. (3) Information from the record and/or the record will be transferred to the appropriate Federal, State, or local agency, or a
member of the public in response to a specific request for pertinent information. (4) Information may also be provided to the Department of
Justice or in a proceeding before a court or adjudicative body; or to Federal, State, local or foreign agencies when needed for enforcement
of civil or criminal codes or applicable regulations concerning title rights upon the public land.
EFFECT OF NOT PROVIDING INFORMATION: Disclosure of this information is required by 30 U.S.C. 28f and 43 CFR Part 3830 for
those qualified claimants wishing to take the small miner waiver allowed. Failure to supply the information required in this form to support
the claimants certification of waiver from payment of the otherwise required maintenance fees will result in the waiver being disallowed
and the mining claims subject to forfeiture by BLM under 30 U.S.C. 28i.
The Paperwork Reduction Act of 1995 requires us to inform you that:
The BLM collects this information to determine if you qualify for a waiver from the payment of $125 per mining claim or site maintenance
fee established in 30 U.S.C. 28f and the implementing regulations at 43 CFR 3830.
Response to this request is required in accordance with the statute to obtain your benefit.
The 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 20 minutes per response, including time to
review instructions, gathering and maintaining data, and completing and reviewing the form. Direct comments regarding this burden
estimate or any other aspect of this form to the U.S. Department of the Interior, Bureau of Land Management (1004-0114), Bureau
Information Collection Clearance Officer (WO-630), Mail Stop 401 LS, 1849 C St., N.W., Washington, D.C. 20240.

(Form 3830-2, page 3)