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

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

Amended OSM-1 Coal Reclamation Fee Report
2.

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

Reporting for ☐ 1st, ☐ 2nd, ☐ 3rd, or ☐ 4th quarter, 20___.
Entity Number ____________________________________
Permit __________________________________________

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

1.

MSHA Number ___________________________________
Mine Name ______________________________________

______________________________________________________________________
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.

State ___________________________________________
Contact Name ____________________________________

_____________________________________________________________________
Signature
Date

3.

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
ockTons
B

.

Enter amended tonnage below:
b. Moisture
(1) Total
.
%
Block C
(2)Enter
Inherent
the difference.between A %
(3)and
Excess
.
%
B below:

a. Gross Tons

.

Block B

b. Moisture
Enter
amended tonnage below:
(1) Total
.
%
(2) Inherent
.
%
Block
C
Enter
difference between
(3)the
Excess
. A and B below:
%

c. Reduced Tons

.

c. Reduced Tons

.

d. Net Tons

.

d. Net Tons

.

e. Rate

$.

f. Calculated Fee $

e. Rate
.

Enter the difference between A and B :

$.

f. Calculated Fee $

.

Block B




Enter amended
+ plustonnage below:

- minus

Block C

Enter the difference between A and B below:

Calculated Fee:
$




.

check
wire transfer

Please explain the changes to your original filing on the back of this form

4.

- Sign an unsworn statement-

- Submit a properly notarized copy of the OSM-1 form-

Subscribed and sworn to before me in my presence the
______ day of __________, 20______.
______________________________________
Notary Public signature
Commission expires:_______
Approved by OMB, no. 1029-0063. Expires 12/31/2017

OR

“I declare under penalty of perjury that the foregoing is true and
correct. Executed on _____ day of ________, 20_____.”
__________________________________________________
Signature