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pdfU.S. Department of the Interior, Office of Surface Mining Reclamation and Enforcement
Part 1 -- OSM-1
2.
Coal Reclamation Fee Report
1.
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
Reporting for ☐ 1st, ☐ 2nd, ☐ 3rd, or ☐ 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 signing below.
This certification covers the following permit number(s):
State
Permit Number
______________________________________________________________________
Signature
Date
3.
Contact name:
Telephone:
Email:
Entity:
4.
Amount Due: $_______________._____
Credits or Amounts
due from previous filings $_______________._____
COMPANY NAME
Total Due: $_______________._____
MAILING ADDRESS
Total Payment: $_______________._____
CITY, ST, ZIP CODE
5.
Check one: ☐ Electronic funds transfer
- Submit a properly notarized copy of the OSM-1 form-
Subscribed and sworn to before me in my presence the
of __________, 20______.
- Sign an unsworn statement-
______ day
______________________________________
Notary Public signature
Commission expires:_______
☐ Check
OR
“I declare under penalty of perjury that the foregoing is true and
correct. Executed on _____ day of ________, 20_____.”
__________________________________________________
Signature
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 12/17 Call 1-800-799-4265, Ext 325 if you have any questions
Part 2 -- OSM-1 Coal Reclamation Fee Report, OSM-1
You must fill out a Part 2 and Part 3 for
Each permit number you are reporting.
6.
7. Permit Number
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
c. TO STOP REPORTING ON THIS PERMIT
CHECK THE APPLICABLE BOX BELOW
1. PMC Auto Mining Complete
.“Mining is complete and all stockpiles have been reported”
2.
RMC Reported Mining Complete
f. Taxpayer I.D.
i. Taxpayer I.D.
“We have transferred this permit to another company”
3. TMC Temporary Mining Complete
.“We have temporarily stopped mining but production is still
possible from this permit”
8. Fee Computation
a. Gross tons
b. Moisture
1. Total
_______________ . ____ ____
____ ____ . ____ ____ ____ ____ %
a. Gross tons
b. Moisture
1. Total
_______________ . ____ ____
____ ____ . ____ ____ ____ ____ %
a. Gross tons
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 Expires12/17
_______________ . ____ ____
$.
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 12/17
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
File Type | application/pdf |
File Title | OSM1Main |
File Modified | 2017-06-15 |
File Created | 2014-05-19 |