Form OSM-1 Coal Production Fee Report

U.S. Department of the Interior, Office of Surface Mining Reclamation and Enforcement

Part 1 -- OSM-1
Coal Reclamation Fee Report
1st,
2nd,
3rd, or
1. Reporting for

2.
4th quarter, 20____.

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

This certification covers the following permit number(s):
State

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

Permit Number

______________________________________________________________________
Signature
Date

_________________________________
_________________________________
_________________________________

3.

Subscribed and sworn to before me in my presence
the ____ day of __________, 20____.

4.

Contact name: ________________________
Telephone: ________________________

________________________________
Notary Public signature

(seal)

Email (If available): ________________________
Entity #: ________________________

My commission expires _______________

Check one:

Electronic funds transfer
Check

5.

Amount Due: $ ______________ . ____
Credits or Amounts
due from previous
filings: $ ______________ . ____
Total Due: $ ______________ . ____
Total Payment: $ ______________ . ____

Title 30 U.S.C. Section 1232 provides that any person, corporate officer, agent or director, on behalf of a coal mine operator who knowingly makes any false statements, representation or certification, or
knowingly fails to make any statement, representation or certification required in this section shall, upon conviction, be punished by a fine of not more than $10,000, or by imprisonment for not more than one
year or both.
Approved by OMB, no.1029-0063. Expires 12/14
Call 1-800-799-4265, Ext 325 if you have any questions.

Part 2 -- OSM-1 Coal Reclamation Fee Report, OSM-1
6.

You must fill out a Part 2 and Part 3 for
Each permit number you are reporting.

7. Permit Number

c.

1st,

2nd,

3rd, or

Mine Name

a. MSHA Number
b. County

Reporting for

Tribe

4th quarter, 20____

State

d. Permittee Name

g. Operator Name

e. Address

h. Address

f. Taxpayer I.D.

i. Taxpayer I.D.

STOP REPORTING ON THIS PERMIT
Coal Production is complete on this permit and all tonnage
has been reported. Effective next quarter, this permit will
no longer appear on my OSM-1 forms.

8. Fee Computation
a. Gross tons
b. Moisture
1. Total

_______________ . ____ ____

a. Gross tons

_______________ . ____ ____

a. Gross tons

_______________ . ____ ____

b. Moisture
____ ____ . ____ ____ ____ ____ % 1. Total

b. Moisture
____ ____ . ____ ____ ____ ____ % 1. Total

____ ____ . ____ ____ ____ ____ %

2. Inherent

____ ____ . ____ ____ ____ ____ %

2. Inherent

____ ____ . ____ ____ ____ ____ %

2. Inherent

____ ____ . ____ ____ ____ ____ %

3. Excess

____ ____ . ____ ____ ____ ____ %

3. Excess

____ ____ . ____ ____ ____ ____ %

3. Excess

____ ____ . ____ ____ ____ ____ %

c. Reduced tons _______________ . ____ ____

c. Reduced tons _______________ . ____ ____

c. Reduced tons _______________ . ____ ____

d. Net tons

d. Net tons

d. Net tons

e. Rate

_______________ . ____ ____
$.

f. Calculated fee $_______________ . ____ ____

e. Rate

_______________ . ____ ____
$.

e. Rate

f. Calculated fee $_______________ . ____ ____

9.

Approved by OMB, no. 1029-0063. Expirees 12/14

_______________ . ____ ____
$.

f. Calculated fee $_______________ . ____ ____

Total calculated fee for this permit number

$ ____________ . ___ ___

If you need more space, please attach additional sheets.

Part 3 -- OSM-1 Coal Reclamation Fee Report, OSM-1
Complete a Part 3 for each permit number you are reporting.
This Information is required under section 402(c) of the
Abandoned Mine Reclamation Act of 1990.

11.

Permit Number

10.

Reporting for

1st,

2nd,

3rd, or

Mine Name

4th quarter, 20____

State

12.

Mineral Owners

Address

City

State

Zip

13.

Purchasers of Coal

Address

City

State

Zip

14.

Coal Delivered to

Address

City

State

Zip

(prep plant, tipple, loading point)
Approved by OMB, no. 1029-0063. Expirees 12/14

If you need more space, please attach additional sheets.

If you pay by Check:
.

Make your check payable to "Office of Surface Mining"

.

Complete the "Payment Deposit Coupon" below to ensure that your account is properly credited

.

Mail your check payment along with the "Payment Deposit Coupon" to:
Office of Surface Mining, Reclamation & Enforcement
P O BOX 979068
ST LOUIS MO 63197-9000

AML Fees Payment Deposit Coupon
OSM-1 Document Number:
Entity Number:
Entity Name:

Year/Quarter:
Enter Amount of Payment(s): $
Enter Check Number(s):

PLEASE INCLUDE THIS COUPON WITH YOUR CHECK TO ENSURE ACCURATE POSTING OF YOUR PAYMENT