Form 3203-1 NOMINATION OF LANDS FOR COMPETITIVE GEOTHERMAL LEASING

Form 3203-1 (April 2011)	UNITED STATES DEPARTMENT OF THE INTERIOR BUREAU OF LAND MANAGEMENT NOMINATION OF LANDS FOR COMPETITIVE GEOTHERMAL LEASING			APPROVAL PENDING OMB NO. 1004-0132 Expires: December 31, 2013
READ INSTRUCTIONS BEFORE COMPLETING
1. Name		1a. Street
1b. City		1c. State		1d. Zip Code
2. Surface managing agency if other than BLM:__________________________________Unit/Project:_______________________________ Legal description of land requested (segregate by public domain and acquired lands): T. R. Section Meridian State County
3. □ Check if this nomination is part of a block nomination. Include supporting information (see instructions).			3a. Total Acres Nominated: ______________________
4. Amount Remitted (43 CFR 3203.12): Filing Fee: $_____________ + Acres x $0.10: $_____________ = Total: $ ________________
5. Nominated lands cannot be included in a lease sale until BLM confirms that leasing conforms to the land use plan and all National Environmental Policy Act requirements have been met. _________________________________________________ ________________________________________________ ____________________ (Printed Name of Nominator or Attorney-in-Fact) ( Signature of Nominator or Attorney-in-Fact) (Date)
Title 18 U.S.C. Sec. 1001 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

A. General

1. Entries must be typed or printed plainly in ink. The nominator must sign the form (item 5) in ink.

2. This offer must be filed in the proper BLM State Office serving the nominated lands. See regulations at 43 CFR 1821.10 for office locations.

3. Submit only one nomination per form.

4. If more space is needed, additional sheets must be attached to each copy of the form submitted.

5. Two or more nominations may be requested to be sold as a block (43 CFR 3203.11). Check the box in Item 3. Block nominations must include information to support your request and whether the lands requested will be identified with a project or unit.

B. Specific

Item 1—Enter the nominator’s name and billing address.

Item 2—Indicate the agency managing the surface use of the land and, for a block nomination, the name of the unit or project of which the land is a part. The nominator may also provide other information that will assist in establishing status of the lands being nominated. The description of land must conform to 43 CFR 3203.10. Each nomination may not exceed 5,120 acres, unless the area to be leased includes an irregular subdivision (43 CFR 3203.10).

Payments: Each nomination must include a filling fee that is found in the fee schedule at 43 CFR 3000.12. If the total acreage nominated contains fractional acreage, the per-acre fee must be rounded up to the next whole acre.

NOTICES

The Privacy Act (5 U.S.C. 552a) and 43 CFR 2.48(d) require that we provide you with the following information:

AUTHORITY: 30 U.S.C. 1001-1028.; 43 CFR Part 3200.

PRINCIPAL PURPOSE: The BLM uses this information to determine whether or not to offer nominated parcels for geothermal leasing and, if the BLM decides to offer the nominated lands for leasing, it also uses the information to assist in the preparation of a Notice of Competitive Geothermal Lease Sale.

ROUTINE USES: (1) The adjudication of the form. (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. (4) Information from the record and/or the record 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: Disclosure of the information is required to process the nomination. If all information is not provided, the nomination may be rejected.

The Paperwork Reduction Act (44 U.S.C. 3501-3521) requires that we provide you with the following information:

The BLM uses this information to determine whether or not to offer nominated parcels for geothermal leasing and, if the BLM decides to offer the nominated lands for leasing, it also uses the information to assist in the preparation of a Notice of Competitive Geothermal Lease Sale.

Response to this request is required 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 currently valid OMB control number.

BURDEN HOURS STATEMENT: The public reporting burden for this form is estimated to average 1 hour per response, including the time for reviewing instructions, gathering and maintaining data, and completing and reviewing the form. You may send 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 (1004-0132), Bureau Information Collection Clearance Officer (WO-630), 1849 C Street, N.W., Washington, D.C. 20240.

(Form 3203-1, Page 2)