Form 3830-2 Maintenance Fee Waiver Certificaiton

Recordation of Location Notices and Mining Claims; Payment of Fees (43 CFR 3832-3838)

3830-002

Waiver from Annual Maintenance Fees (43 CFR 3835, Subpart A)

OMB: 1004-0114

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Form 3830-2
(November 2010)

UNITED STATES
DEPARTMENT OF THE INTERIOR
BUREAU OF LAND MANAGEMENT

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FORM APPROVED
OMB NO. 1004-0114
Expires: August 31, 2013

MAINTENANCE FEE WAIVER CERTIFICATION
SEE INSTRUCTIONS ON PAGE 2

1.	 This	small	miner	waiver	is	filed	for	the	assessment	year	beginning	on	September	1,	________ and	ending	on	September	1, ________
2.	 The undersigned and all related parties owned ten or fewer mining claims , mill, or tunnel sites located and maintained on Federal lands in the United States
of America on September 1, ________ .
3.	 The	undersigned	have	performed	the	assessment	work	required	by	law	for	each	mining	claim	listed	prior	to	filing	this	waiver	and	understand	that	by	filing	this	form,	
the	undersigned	must	file	an	affidavit	of	assessment	work	with	the	Bureau	of	Land	Management	(BLM)	by	the	December	30th	following	the	filing	of	this	waiver.
4.	 The	undersigned	understand	that	if	the	assessment	work	obligation	has	not	yet	come	due	under	30	U.S.C.	28	(for	those	claims	in	their	first	assessment	year	only),
a	notice	of	intent	to	hold	reciting	this	condition	must	be	recorded	by	the	December	30th	following	the	filing	of	this	waiver.
5.	 The	undersigned	understand	that	mill	and	tunnel	sites	may	also	be	listed	on	this	waiver	and	be	waived	from	payment	of	the	maintenance	fee,	and	that	a	notice	of	
intent	to	hold	for	these	sites	is	required	to	be	filed	with	the	BLM	by	the	December	30th	following	the	filing	of	this	waiver.
6.	 The	undersigned	understand	and	acknowledge	that	pursuant	to	43	U.S.C.	1212	and	18	U.S.C.	1001,	the	filing	or	recording	of	a	false,	fictitious,	or	fraudulent
document	with	the	BLM	may	result	in	a	fine	of	up	to	$250,000,	a	prison	term	not	to	exceed	five	years,	or	both.
7.	 The	mining	claims,	mill	or	tunnel	sites	for	which	this	waiver	from	payment	of	the	maintenance	fees	is	requested	are:

BLM RECORDATION SERIAL NUMBER

CLAIM OR SITE NAME

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
The owner(s) (claimants) of the above mining claims and sites are:

____________________________________________________ 	
	
(Owner’s Name - Please Print)

_____________________________________________________

____________________________________________________ 	
	
(Owner’s	Mailing	Address)	

______________________________ 	

____________________________________________________ 	
	
(Owner’s Name - Please Print)

_____________________________________________________

____________________________________________________ 	
	
(Owner’s	Mailing	Address)	

______________________________ 	

____________________________________________________ 	
	
(Owner’s Name - Please Print)

_____________________________________________________

____________________________________________________ 	
	
(Owner’s	Mailing	Address)	

______________________________ 	

____________________________________________________ 	
	
(Owner’s Name - Please Print)

_____________________________________________________

____________________________________________________ 	
	
(Owner’s	Mailing	Address)	

______________________________ 	

(Continued on page 2)

(Owner’s Signature)
(City)	

_________	 ____________
(State)	

(Zip	Code)

(Owner’s Signature)
(City)	

_________	 ____________
(State)	

(Zip	Code)

(Owner’s Signature)
(City)	

_________	 ____________
(State)	

(Zip	Code)

(Owner’s Signature)
(City)	

_________	 ____________
(State)	

(Zip	Code)

____________________________________________________ 	
	
(Owner’s Name - Please Print)

_____________________________________________________

____________________________________________________ 	
	
(Owner’s	Mailing	Address)	

______________________________ 	

____________________________________________________ 	
	
(Owner’s Name - Please Print)

_____________________________________________________

____________________________________________________ 	
	
(Owner’s	Mailing	Address)	

______________________________ 	

____________________________________________________ 	
	
(Owner’s Name - Please Print)

_____________________________________________________

____________________________________________________ 	
	
(Owner’s	Mailing	Address)	

______________________________ 	

____________________________________________________ 	
	
(Owner’s Name - Please Print)

_____________________________________________________

____________________________________________________ 	
	
(Owner’s	Mailing	Address)	

______________________________ 	

(Owner’s Signature)

(City)	

_________	 ____________
(State)	

(Zip	Code)

(Owner’s Signature)

(City)	

_________	 ____________
(State)	

(Zip	Code)

(Owner’s Signature)

(City)	

_________	 ____________
(State)	

(Zip	Code)

(Owner’s Signature)

(City)	

_________	 ____________
(State)	

(Zip	Code)

18 U.S.C. 1001 and 43 U.S.C. 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.
INSTRUCTIONS
This	certification	is	made	under	the	provisions	of	43	U.S.C.	§	1744	and	30	U.S.C.	§28-28k	and	the	regulations	thereunder	(43	CFR	Part	3830).
The	claimant(s)	must	fill	in	the	dates	in	paragraph	1	for	the	beginning	and	ending	of	the	assessment	year	for	which	this	waiver	is	sought.
The	claimant(s)	must	fill	in	the	date	in	paragraph	2	for	the	beginning	of	the	assessment	year	for	which	this	waiver	is	sought.
All	claim	and	site	names	and	BLM	serial	numbers	must	be	listed	for	the	mining	claims,	mill	sites,	and	tunnel	sites	for	which	the	waiver	is	sought.
All	owners	of	the	mining	claims,	mill	sites,	and	tunnel	sites	and	their	addresses	must	be	given.
This	waiver	form	must	be	signed	by	all	the	claimants	or	their	designated	agent,	in	original	form.	If	an	agent	is	designated,	a	notarized	designation	of
agent,	signed	by	all	of	the	claimants	with	proper	address	given,	must	be	submitted	with	this	waiver.
7.	 This	form	must	be	filed	no	later	than	September	1st	for	the	upcoming	assessment	year	in	the	BLM	State	Office	where	the	mining	claims	or	sites	are
recorded,	or	the	waiver	cannot	be	granted	by	the	BLM.	(Example:	To	obtain	a	waiver	for	the	assessment	year	2012,	which	begins	on	September	1,	2011,
you	must	qualify	for	and	file	for	a	waiver	no	later	than	September	1,	2011,	in	the	proper	BLM	State	Office.)
8.	 For	all	mining	claims	which	require	assessment	work,	you	must	record	an	affidavit	of	labor	on	or	before	the	December	30th	immediately	following	the
filing	of	this	waiver.	For	all	other	mining	claims	or	sites	waived,	you	must	record	a	notice	of	intent	to	hold	on	or	before	the	December	30th	immediately
following	the	filing	of	this	waiver.
9.	 Mill	and	tunnel	sites	may	also	be	listed	on	this	waiver	and	be	waived	from	payment	of	the	maintenance	fee.	A	notice	of	intent	to	hold	for	these	sites	is	
required	to	be	filed	by	the	December	30th	following	the	filing	of	this	waiver.	
1.	
2.	
3.	
4.	
5.	
6.	

FOR OFFICIAL USE ONLY

(Continued on page 3)	

(Form 3830-2, page 2)

NOTICES
The Privacy Act	and	43	CFR	2.48(d)	require	that	you	be	furnished	the	following	information	in	connection	with	the	information
	requested	by	this	form.
AUTHORITY:	30	U.S.C.	28f	and	43	CFR	part	3835	permit	collection	of	the	information	requested	by	this	form.
PRINCIPAL	PURPOSE:	The	BLM	will	use	the	information	you	provide	to	verify	that	the	owner(s)	(claimants(s))	of	a	mining	claim	
has/have	complied	with	30	U.S.C.	28f	and	43	CFR	part	3835	and	is/are	entitled	to	perform	assessment	work	in	lieu	of	paying	the	maintenance	
fee	for	the	mining	claims	listed	on	this	form.
ROUTINE	USES:	The	BLM	will	only	disclose	this	information	in	accordance	with	the	provisions	at	43	CFR	2.56(b)	and	(c).
EFFECT	OF	NOT	PROVIDING	INFORMATION:	Disclosure	of	the	requested	information	is	required	by	30	U.S.C.	28f	and	
43	CFR	part	3835	for	those	claimants	qualified	to	request	the	small	miner	waiver	allowed.	Failure	to	submit	all	the	requested	information	
or	to	complete	this	form	will	delay	the	BLM’s	processing	of	the	form	and	may	preclude	the	BLM’s	acceptance	of	the	maintenance	
fee	waiver	request,	which	may	result	in	forfeiture	of	the	mining	claim	or	site	by	the	claimant.
The Paperwork Reduction Act	requires	us	to	inform	you	that:
The	BLM	collects	this	information	to	determine	whether	or	not	you	are	qualified	for	waiver	of	maintenance	fees.
Submission	of	the	requested	information	is	necessary	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:	Public	reporting	burden	for	this	form	is	estimated	to	average	20	minutes	per	response,	including	the	
time	for	reviewing	instructions,	gathering	and	maintaining	data,	and	completing	and	reviewing	the	form.	You	may	submit	comments	
regarding	the	burden	estimate	or	any	other	aspect	of	this	form	to:	U.S.	Department	of	the	Interior,	Bureau	of	Land	Management	
(1004-0114),	Bureau	Information	Collection	Clearance	Officer	(WO-630),	Mail	Stop	401	LS,	1849	C	St.,	N.W.,	Washington,	D.C.	20240.

		

(Form 3830-2, page 3)


File Typeapplication/pdf
File TitleBLM Form 3830-2 (November 2010)
SubjectElectronic Form Created On 11/10/10
AuthorNPC, Inc.
File Modified2011-03-04
File Created2010-11-09

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