ONRR 4435 Appeal Bond

U.S. Department of the Interior OMB Control Number 1012-0006

Office of Natural Resources Revenue OMB Approval Expires January 31, 2015

ADMINISTRATIVE APPEAL BOND

Form ONRR-4435

Bond No. __________________ Bond Amount $_____________________

Date Bond Executed _________________

KNOW ALL MEN BY THESE PRESENTS, That we, _____________________________ as Principal, and ________________________, a corporation duly organized and existing under the laws of the State of ______________________, having its main office at ________________________________________, as Surety are held and firmly bound unto the United States Office of Natural Resources Revenue in the sum of $____________________, for the payment of which sum well and truly to be made, we bind ourselves, and our heirs, executors, administrators, jointly and severally, firmly by these presents.

THE CONDITION OF THIS OBLIGATION IS SUCH THAT, WHEREAS, the bond is intended to secure the payment of principal and interest due the United States Office of Natural Resources Revenue in the event that __________________________ is unsuccessful in its administrative appeal to the Director, Office of Natural Resources Revenue, of (Bill Number(s))_____________________________, dated ________________, or any order (invoice) which may be substituted, if__________________ shall pay all principal and interest found to be due under the decision on that appeal within the time required therefor, this instrument shall be of no force or effect; otherwise, it will remain in full force and effect.

Principal Surety

_________________________________ _________________________________

(Legal Name) (Legal Name)

_________________________________ _________________________________

(Address) (Address)

_________________________________ _________________________________

By_______________________________ _________________________________

Its ______________________________ _________________________________

Corporate Seal (where required)

Paperwork Reduction Act of 1995 (PRA) Statement: The PRA (44 U.S.C. 3501 et seq.) requires us to inform you that we collect this information to allow lessees, designees, or payors to stay the effectiveness of an order or decision by posting a surety instrument. The ONRR uses the information to secure the financial interests of the public and Indian lessors during the entire administrative and judicial appeal process. Responses are required to obtain a benefit (43 U.S.C. 1334). Proprietary information is protected in accordance with standards established by the Federal Oil and Gas Royalty Management Act of 1982 (30 U.S.C. 1733), the Freedom of Information Act

(5 U.S.C. 552(b)(4)), and Department regulations (43 CFR 2). An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Public reporting burden for this form is estimated to average 2 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 Rules and Regs Team, Office of Natural Resources Revenue, PO Box 25165, MS 61030A, Denver, CO 80225.

Form ONRR-4435 (revised 10/2011)