Form E Form for Officer to Execute Papers

OMB Control No. 1076-0180

Expiration Date xx/xx/xxxx

FORM E

Approved by the Secretary of the Interior March 20, 1952

OSAGE MINING LEASES

. C_O_N_T_RA_C_T_N_U_M_B_E_R

_,.J

'

EVIDENCE OF AUTHORITY OF OFFICERS TO EXECUTE PAPERS

(To be sworn to by Secretary and President of a corporation and sealed with its seal.)

I solemnly swear that and

were on the day

of 20 , the duly elected, qualified and acting president and secretary, respectively, of

a corporation organized under the laws of --,- _ on which day they executed

--------------mining lease for and in behalf of said corporation as lessee, covering certain lands of the Osage Tribe; that they were fully empowered to execute said _. lease and all papers in connection therewith, and that their action in executing the same binds the said 9orporation to full performance of all obligations thereunder.

This day of 20

(CORPORATE SEAL)

President

Secretary·

Subscribed and sworn to before me this day of ,20 .

Notary Public

My commission expires:

Paperwork Reduction Act Statement: We are collecting this information subject to the Paperwork Reduction Act (44 U.S.C. 3501) to ensure authority to enter into lease on behalf of the corporate entity and ensure existence of corporate entity. Your response is voluntary and we will not share the results publicly. We may not conduct or sponsor and you are not required to respond to a collection of information unless it displays a currently valid OMB Control Number. OMB has reviewed and approved this survey and assigned OMB Control Number 1076-0180, which expires ##/##/####.

Estimated Burden Statement: We estimate the form will take you 60 minutes to complete, including time to read instructions, gather information, and complete and submit the form. You may submit comments on any aspect of this information collection to the Information Collection Clearance Officer, Office of Regulatory Affairs & Collaborative Action—Indian Affairs (RACA), U.S. Department of the Interior, 1001 Indian School Road NW, Suite 229, Albuquerque, NM 87104.