Form Amended OSM-1 Amended OSM-1 Coal Reclamation Fee Report

Amended OSM-1

Reporting for

Coal Reclamation Fee Report

1st, 2nd, 3rd, or 4th quarter, 20_________

Entity Number _____________________________________________

Use this form to change an OSM-1 report already submitted.
Send this form with any supporting documentation along with
a check or wire transfer for applicable fees to:

Permit Number ____________________________________________
MSHA Number ____________________________________________
Mine Name _______________________________________________
State _____________________________________________________

Office of Surface Mining Reclamation and Enforcement
P.O. Box 979068
St. Louis, MO 63197-9000

Contact Name ______________________________________________
Telephone Number _________________________________________

Block A

Block B

Block C

Enter originally reported tonnage below:

Enter amended tonnage below:

Enter the difference between A and B below:

a. Gross Tons
b. Moisture
(1) Total
(2) Inherent
(3) Excess

__________ . ___ ___

a. Gross Tons

__________ . ___ ___

__ __ . __ __ __ __ %
__ __ . __ __ __ __ %
__ __ . __ __ __ __ %

b. Moisture
(1) Total
(2) Inherent
(3) Excess

__ __ . __ __ __ __ %
__ __ . __ __ __ __ %
__ __ . __ __ __ __ %

c. Reduced Tons __________ . ___ ___

c. Reduced Tons __________ . ___ ___

d. Net Tons

d. Net Tons

e. Rate

__________ . ___ ___
$ . ___ ___ ___ ___

f. Calculated Fee $__________ . ___ ___

e. Rate

__________ . ___ ___
$ . ___ ___ ___ ___

f. Calculated Fee $__________ . ___ ___

Enter the difference between A and B :




+ plus
- minus

Calculated Fee:
$______________ . ___ ___




check
wire transfer

Please explain the changes to your original filing on the back of this form
I hereby certify that the statements made herein are true, complete and
correct to the best of my knowledge and belief and are made in good faith.

Subscribed and sworn to before me in my presence the
________ day of ____________________, 20 ______

____________________________________________________________
Print in ink or type the name of the reporting person, corporate officer, agent,
or director on behalf of the operator or the permittee.

___________________________________

(seal)

Notary Public Signature

____________________________________________________________
Signature

Approved by OMB, no. 1029-0063. Expires 12/31/2014

Date

My commission expires _________________