Form 3860-5 Application for Survey of Mining Claim

FORM APPROVED
OMB NO. 1004-0025
Expires: March 31, 2013

UNITED STATES
DEPARTMENT OF THE INTERIOR
BUREAU OF LAND MANAGEMENT
APPLICATION FOR SURVEY OF MINING CLAIM

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Hereby makes application for an official mineral survey of the mining claims named and identified in this application

BLM

NAME OF LOCATION

RECORDED

WlTH

CLAIM

SERIAL

NUMBER

Township
National Forest
5a. Is each claim based on a valid location and fully described in the certified copy of the record of each location certificate filed with this application?
b. Is each location distinctly marked by monuments on the ground and can its boundaries be traced readily?

Yes

money order

certified check, made payable to the Bureau of Land Management,

in the amount of $
7. It is requested that the survey be made, in accordance with the regulations, by the following U.S. Mineral surveyor.

Date

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agency of the United States any false, fictitious, or fraudulent statements or representations as to any matter within its jurisdiction.

be occupied or used in connection with mining activity.

Idaho, Boise; Nevada, Reno; Washington and Oregon, Portland; Utah,
3. Name the claimant (individual, partnership, company or corporation)

4.

claimant or an authorized agent.
copies of the record of the location certificate
the records where mining claims are recorded, usually the Clerk of the

mineral surveyors and to make satisfactory settlement arrangements for

additional location or millsite to cover the cost of office expense, must
be made with the Bureau of Land Management before an order for the
each State Office may require a deposit that is sufficient to cover their
estimate of each order for survey. If this deposit is insufficient to cover

ground. If a location certificate has been amended and the survey is to

locations constituting the claim for which an official survey is desired.

Several locations may be embraced in as single survey only when they

NOTICES

THE PRIVACY ACT and the regulation in 43 CFR 2.48(d) provide that you be furnished the
following information in connection with information required by this application.
AUTHORITY: 30 U.S.C. 22, 29, 39, 43 CFR 3861.1.
PRINCIPAL PURPOSE: The information will be used to process your application for a
mineral survey.
ROUTINE USES: (1) The adjudication of the applicant’s rights to the land or resources; (2)
documentation for public information in support of notations made on land status records for the
management, disposal, and use of public lands and resources; (3) transfer to appropriate Federal
agencies when concurrence is required prior to granting a right in public lands or resources; and
(4) either specific information from the record or the complete record itself will be transferred to

appropriate Federal, State, local or foreign agencies, when relevant to civil, criminal or

regulatory investigations or prosecutions.

EFFECT OF NOT PROVIDING INFORMATION: The application may be rejected.

THE PAPERWORK REDUCTION ACT requires us to inform you that:
The BLM collects this information to properly provide the requested service. The information
provided will be used to determine the level of service required. Submission of the requested
information is necessary to obtain or retain a benefit. You do not have to respond to this or any
other Federal agency-sponsored information collection unless it displays a 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. You may submit comments regarding
the burden estimate or any other aspect of this form to: U.S. Department of the Interior, Bureau
of Land Management (1004-0025), Bureau Information Collection Clearance Officer (WO-630),
1849 C St., N.W., Room 2134LM, Washington, D.C. 20240.

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                                                                                                                                                                                                (Form 3860-5, page 3)