3504-3 Bond Under Lease for Mining ____ Deposits

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Form 3504-3
(March 2010)

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

UNITED STATES
DEPARTMENT OF THE INTERIOR
BUREAU OF LAND MANAGEMENT
MINING

Serial Number

BOND* UNDER LEASE FOR
DEPOSITS

Bond Number

Know All Men By These Presents, That
of

, as principal,

and
of

, as surety,

are 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, we bind
ourselves, and each of us, and each of our heirs, executors, administrators, and successors, jointly and severally,
firmly by these presents.
The conditions of this obligation are such, that whereas the said principal entered into a lease of the lands described
therein and upon conditions therein expressed, which lease bears the above serial number.
now, Therefore, if the said principal, his heirs, executors, administrators, or successors, will faithfully carry
out the obligations and observe the requirements of said lease, and will duly keep, perform, and abide by each and
every term and provision of said lease as therein stipulated and agreed, then this obligation will be null and void;
otherwise to remain in full force and effect.
Signed on this

day of

(Signature of Witness)

, 20

(Printed Name of Witness)

(Address of Witness)

(Signature of Witness)

(Printed Name of Witness)

, in the presence of:

(Signature of Principal)

(Address of Principal)

(Signature of Surety)

(Address of Witness)

(Signature of Witness)

(Printed Name of Witness)

(Address of Witness)

(Printed Name of Signer)

(Printed Name of Signer)

(Address of Surety)

(Signature of Surety)

(Printed Name of Signer)

(Address of Surety)

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.
* This form of bond may be used in connection with coal, phosphate, and sodium leases, Act of February 25, 1920, as amended (30 U.S.C. 181 et seq.); potassium
leases, Act of February 7, 1927, as amended (30 U.S.C. 281 et seq.); sulphur leases, Act of April 17, 1926, as amended (30 U.S.C. 271 et seq.); all such leases
involving acquired lands, Act of August 7, 1947 (30 U.S.C. 351), and asphalt leases, Act of June 28, 1944 (58 Stat. 463, 483-485), by inserting the particular mineral
applicable in the space provided therefore. If this bond is executed by a corporation, it must bear the corporate seal.
(Continued on 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 CFR Parts 3400 and 3500
PRINCIPAL PURPOSE: The 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.
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 a mineral lease.
The Paperwork Reduction Act of 1995 requires us to inform you that:
BLM collects this information to comply with the regulations at 43 CFR Parts 3400 and 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 fail to perform under
the terms, conditions, and stipulations of their mineral leases.
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 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.

(Form 3504-3, page 2)