Form 3830-003 NOTICE OF INTENT TO LOCATE A LODE OR PLACER MINING CLAIM

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TO ALL WHOM IT MAY CONCERN:

This notice is filed under Public Law No. 103-23 of April 16, 1993 (107 Stat. 60), entitled “An Act to amend the Stock Raising Homestead Act to resolve certain problems regarding subsurface estates, and for other purposes.” The undersigned place(s) all interested parties on notice that, within 90 days of filing this notice with the Bureau of Land Management (BLM) and after 30 days from the date of receipt of a copy of this notice by the surface owner(s) of a record, the undersigned intend(s) to enter the lands described below to explore for a valuable mineral deposit(s) and to locate a mining claim(s), and/or tunnel site(s), as provided under the mining laws of the United States (30 U.S.C. 22, et seq.). The area covered by this notice and all other notices filed by the undersigned and any affiliate(s) of the undersigned, and which continue to be in effect on the date of this filing does not exceed 6,400 acres of such land in any one State and 1,280 acres of such land for a single entity. This notice, for a single State and surface of ownership, covers the following lands:

1/4	SECTION	TOWNSHIP	RANGE	MERIDIAN

in County, State of .

Total acres under this notice .

^{Name(s), telephone number(s), and mailing address(es) of affected surface owner(s):} Name(s), telephone number(s), and mailing address(es) of person(s) filing this notice:

Brief description of the proposed casual use exploration activities (i.e., activities that cause no more than a minimal disturbance to the surface resources and do not involve the use of mechanized earth-moving equipment, explosives, the construction of access roads, drill pads, or the use of toxic or hazardous materials):

Date(s) on which such activities will take place:

(Continued on page 2)

Attached is a map showing the existing access routes proposed to be used for casual use exploration purposes, primary areas of interest, and types of activities to be conducted.

The above described activities will be managed by:

Name

Mailing Address

Phone Number (include area code)

Dated this day of , 20 .

Signature of:

(Person) (Affiliate)

RECORDER’S STAMP

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.

NOTICES

The Privacy Act and 43 CFR 2.223(d) require that you be furnished with the following information in connection with the information requested by this form.

AUTHORITY: 43 U.S.C. 299(b) and 43 CFR subpart 3814 and part 3838 permit collection of the information requested by this form. PRINCIPAL PURPOSE: The BLM will use the information you provide to verify that you have complied with the pre-location requirements at

43 U.S.C. 299(b) and 43 CFR subpart 3814 and part 3838, and are therefore qualified to locate and record mining claims on land patented under the Stock Raising Homestead Act.

ROUTINE USES: The BLM will only disclose this information in accordance with the provisions at 43 CFR 2.231(b) and (c).

EFFECT OF NOT PROVIDING INFORMATION: Disclosure of the requested information is required by 43 U.S.C. 299(b) and 43 CFR subpart 3814

and part 3838 for mining claimants who desire to locate a mining claim or tunnel site on land previously patented under the Stock Raising Homestead Act. Failure to comply and submit all the requested information or to complete this form will delay the BLM’s processing of the form or may preclude the BLM’s acceptance of your notice of intent to locate (NOITL) a mining claim or site on lands patented under the Stock Raising Homestead Act. Failure to comply with the requirements of 43 U.S.C. 299(b) and 43 CFR subpart 3814 and part 3838 will void your NOITL. Mining claims or sites located under a void NOITL are null and void from the beginning and will be cancelled by the BLM.

RELEVANT SYSTEM OF RECORDS NOTICE (SORN) CITATION: The Recordation of Mining Claims SORN may be found at 47 FR 55326 (December 8, 1982).

The Paperwork Reduction Act requires us to tell you that:

The BLM collects this information to determine whether or not you are qualified to locate a lode or placer mining claim and/or tunnel site on lands patented under the Stock Raising Homestead Act.

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 25 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), 1849 C St., N.W., Mail Stop 401 LS, Washington, D.C. 20240.

(Form 3830-3, page 2)