AML Contractor Information

OMB #1029-0119

Expiration Date: 1/31/13

AML CONTRACTOR INFORMATION FORM

You must complete this form for your AML contracting officer to request an eligibility evaluation from the Office of Surface Mining to determine if you are eligible to receive an AML contract. This requirement applies to contractors and their sub-contractors and is found under OSM’s regulations at 30 CFR 874.16. When possible, please type your information onto this form to reduce errors on our end. NOTE: Signature and date of this form must be recent (within the last month) to be considered for a current bid.

Part A: General Information

Business Name: ______________________________ Tax Payer ID No.: _______________

Address: ____________________________________________________________________

City: ____________________ State: ________ Zip Code: ________ Phone: ______________

Fax No.: ___________________ E-mail address: _______________________

Part B: Legal Structure

( ) Corporation ( ) Sole Proprietorship ( ) Partnership ( ) LLC

( ) Other (please specify) ______________________________________________________

Part C: Certifying and updating information in the Applicant/Violator System (AVS). Select only one of the following options, follow the instructions for that option, and sign below.

I, __________________________________, have the express authority to certify that:

(print name)

1. ______Information on the attached Entity Organizational Family Tree (OFT) from AVS is accurate, complete, and up-to-date. If you select this option, you must attach an Entity OFT from AVS to this form. Sign and date below and do not complete Part D.

2. ______Part of the information on the attached Entity OFT from AVS is missing or incorrect and must be updated. If you select this option, you must attach an Entity OFT from AVS to this form. Use Part D to provide the missing or corrected information. Sign and date below and complete Part D.

3.______Our business currently is not listed in AVS. If you select this option, you must provide all information required in Part D. Sign and date below and complete Part D.

_____________ ________________________________ _________________

Date Signature Title

IMPORTANT! In order to certify in Part C to the accuracy of existing information in AVS, you must obtain a copy of your business’ Entity OFT. To obtain an Entity OFT, contact the AVS Office, toll-free, at 800-643-9748 or from the AVS website at https://avss.osmre.gov.

Part D.

Contractor’s Business Name: ____________________________________________

If the current Entity OFT information for your business is incomplete or incorrect in AVS, or if there is no information in AVS for your business, you must provide all of the following information as it applies to your business. Please make as many copies of this page as you require.

• Every officer (President, Vice President, Secretary, Treasurer, etc.);

• All Directors;

• All persons performing a function similar to a Director;

• Every person or business that owns 10% or more of the voting stock in your business;

• Every partner, if your business is a partnership;

• Every member and manager, if your business is a limited liability company; and

• Any other person(s) who has the ability to determine the manner in which the AML reclamation project is being conducted.

Name Position/Title

Address Telephone #

% of Ownership

Begin Date: Ending Date:

Name Position/Title

Address Telephone #

% of Ownership

Begin Date: Ending Date:

Name Position/Title

Address Telephone #

% of Ownership

Begin Date: Ending Date:

Name Position/Title

Address Telephone #

% of Ownership

Begin Date: Ending Date:

PAPERWORK REDUCTION STATEMENT

The Paperwork Reduction Act of 1995 (44 U.S.C. 3501) requires us to inform you that: Federal Agencies 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. This information is necessary for all successful bidders prior to the distribution of AML funds, and is required to obtain a benefit.

Public reporting burden for this form is estimated to range from 15 minutes to 1 hour, with an average of 26 minutes per response, including time for reviewing instructions, gathering and maintaining data, and completing and reviewing the form. You may direct comments regarding the burden estimate or any other aspect of this form to the Information Collection Clearance Officer, Office of Surface Mining Reclamation and Enforcement, Room 203 SIB, Constitution Ave., NW, Washington, D.C. 20240.