Form 3504-1 Personal Bond and Power of Attorney Under ___ Mineral Le

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Form 3504-1
(March 2010)

FORM APPROVED
OMB NO. 1004–0121
Expires: February 28, 2013

UNITED STATES
DEPARTMENT OF THE INTERIOR
BUREAU OF LAND MANAGEMENT

Serial Number

PERSONAL BOND* AND POWER OF ATTORNEY
UNDER  MINERAL LEASE OR
FOR MINING



PROSPECTING PERMIT
DEPOSITS

Bond Number
Office

Know All Men By These Presents, That
, as obligor, is held and
firmly bound unto the United States in the sum of
($

dollars,

), lawful money of the United States, for the payment of which, well and truly to be made, he binds

himself, his heirs, executors, administrators, and successors, jointly and severally, firmly by these presents.

The conditions of this obligation are such, that whereas the above-named obligor entered into a mineral lease or prospecting permit of the lands described therein upon conditions therein expressed, which mineral lease or prospecting
permit bears the above serial number.
now, Therefore, if the said obligor, his heirs, executors, administrators, or successors, will faithfully carry out
the obligations and observe the requirements of said mineral lease or prospecting permit and will duly keep, perform,
and abide by each and every term and provision of said mineral lease or prospecting permit as therein stipulated and
agreed, then this obligation will be null and void; otherwise to remain in full force and effect.
That said obligor, in order the more fully to secure the United States in the payment of the aforesaid sum, hereby
pledges cash as security therefor or negotiable bonds of the United States, of a par value equal to the amount specified,
which said bonds are numbered serially and are in the denominations and amounts and are otherwise more particularly described as follows:

bonds of $

, bearing

percent interest, with

coupons attached to each numbered

which said bonds have been deposited with the Secretary of the Interior.

* This form of bond may be used in connection with phosphate, and sodium mineral leases or prospecting permits, Act of February 25, 1920, as amended (30 U.S.C. 181 et seq.); potassium mineral leases or prospecting permits, Act of February 7, 1927, as
amended (30 U.S.C. 281 et seq.); sulphur mineral leases or prospecting permits, Act of April 17, 1926, as amended (30 U.S.C.
271 et seq.); all such mineral leases or prospecting permits involving acquired lands, Act of August 7, 1947, (30 U.S.C. 351),
and asphalt mineral leases or prospecting permits, Act of June 28, 1944, as amended (25 U.S.C. 561–562), by inserting the particular

mineral

applicable

in

the

space

provided

therefor. This

form

is

for

use

where

the

mineral

lease

or

prospecting

permit

covers either public lands or lands embraced in an entry or patent subject to the reservation of potassium, phosphate, or sodium
deposits to the United States under the Act of July 17, 1914 (30 U.S.C. 121–123); pursuant to the Act of June 22, 1910 (30 U.S.C.
83–85), pursuant to the Act of March 8, 1922 (48 U.S.C. 376–377); or of sulphur pursuant to the Act of March 4, 1933 (30 U.S.C.
124). If this bond is executed by a corporation, it must bear the corporate seal.
(Continued on page 2)

That the said obligor does hereby constitute and appoint
the Secretary of the Interior as his attorney, for him
and in his name to collect or to sell, assign, and transfer the said cash or United States bonds above-described
and deposited by the obligor, as aforesaid, pursuant to
authority conferred by section 1 of the Act of July 30,
1947 (61 Stat. 646; 6 U.S.C. 15), as security for the
faithful performance of any and all of the conditions
or stipulations as hereinbefore set out, and it is agreed
that, in case of any default in the performance of the
conditions and stipulations of such undertaking the
said attorney must have full power to collect said
bonds or any part thereof, or to sell, assign, and transfer said bonds or any part thereof without notice, at

Signed on this

day of

, 20

public or private sale, free from any equity of redemption or without appraisement or valuation, notice and
right to redeem being waived, and to apply proceeds
of such sale or collection to the full amount of the
bond to the satisfaction of any damages, or deficiencies
arising by reason of such default, as said attorney
may deem best. The interest accruing upon said United
States bonds deposited as above stated, in the absence
of any default in the performance of any of the conditions or stipulations of the bond, must be paid to said
obligor. The said obligor hereby for himself, his heirs,
executors,
administrators,
and
successors,
ratifies
and confirms whatever his said attorney must do by
virtue of these presents.

, in the presence of:

(Printed Name of Witness)

(Printed Name of Obligor)

(Signature of Witness)

(Signature of Obligor)

(Address of Witness)

(Address of Obligor)

Title 18 U.S.C. Section 1001 and Title 43 U.S.C. Section 1212, make 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.
(Continued on page 3)

(Form 3504-1, page 2)

NOTICES
The Privacy Act of 1974 and the regulation in 43 CFR 2.48(d) provide that you be furnished with the following
information in connection with information required by this bond form.
AUTHORITY: 30 U.S.C. 181 et seq., 43 U.S.C. 3500
PRINCIPAL PURPOSE: Bureau of Land Management (BLM) will use the information you provide to ensure that
the United States is fully indemnified against failure to perform under the terms, conditions and stipulations of a
mineral lease or prospecting permit.
ROUTINE USES: BLM will disclose information to: (1) appropriate Federal, State, local or foreign agencies, when
relevant to civil, criminal, or regulatory investigations or prosecutions; (2) appropriate Federal agencies when their
concurrence is required before BLM grants a right in public lands or resources; (3) a member of the public in
response to a specific request for pertinent information; (4) a congressional office in response to an inquiry made at
the request of an individual; and (5) to a consumer reporting agency to expedite collecting debts owed the
government.
EFFECT OF NOT PROVIDING INFORMATION: Filing of this information is required to obtain and keep a
benefit. If you do not provide a bond, BLM will not issue you a prospecting permit or lease .
The Paperwork Reduction Act of 1995 requires us to inform you that:
BLM collects this information to comply with the regulations of 43 CFR 3500, which implement the provisions of
the Mineral Leasing Act of 1920, as amended; the Mineral Leasing Act for Acquired Land of 1947; and section 402
of Reorganization Plan No. 3 of 1946.
BLM uses the information to protect the interests of the United States in cases where lessees or permittees fail to
perform under the terms, conditions, and stipulations of their mineral leases or permits.
Response to this request is required to obtain and keep a benefit.
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 4 hours per
response, including the time for reviewing instructions, gathering and maintaining data, and completing and
reviewing the form. Direct comments regarding the burden estimate or any other aspect of this form to the U.S.
Department of the Interior, Bureau of Land Management (1004-0121), Bureau Information Collection Clearance
Officer (WO-630), 1849 C Street, N.W., Mail Stop 401 LS, Washington, D.C. 20240.

(BLM Form 3504-1, page 3)