Fillable FORM APPROVED: AFFIDAVIT OF ANNUAL ASSESSMENT WORK (Bureau of Land Management - Main Domain)

Fill Online, Printable, Fillable, Blank FORM APPROVED: AFFIDAVIT OF ANNUAL ASSESSMENT WORK (Bureau of Land Management - Main Domain) Form

Use Fill to complete blank online BUREAU OF LAND MANAGEMENT - MAIN DOMAIN (CO) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

FORM APPROVED: AFFIDAVIT OF ANNUAL ASSESSMENT WORK (Bureau of Land Management - Main Domain)

On average this form takes 38 minutes to complete

The FORM APPROVED: AFFIDAVIT OF ANNUAL ASSESSMENT WORK (Bureau of Land Management - Main Domain) form is 3 pages long and contains:

  • 2 signatures
  • 0 check-boxes
  • 145 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Bureau of Land Management - Main Domain

BROWSE BUREAU OF LAND MANAGEMENT - MAIN DOMAIN (CO) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Form 3830-004
(January 2020)
UNITED STATES
DEPARTMENT OF THE INTERIOR
BUREAU OF LAND MANAGEMENT
AFFIDAVIT OF ANNUAL ASSESSMENT WORK
FORM APPROVED
OMB NO.: 1004-0114
Expires: April 30, 2023
WHEN RECORDED, MAIL DOCUMENT TO:
NAME:
ADDRESS:
CITY, STATE, ZIP:
FOR COUNTY RECORDER’S USE
No. of Claims
x $15/claim
Total due BLM $
TO ALL WHOM IT MAY CONCERN:
1.
The undersigned certifies that at least $100 per claim was expended for development, labor and improvements, or equivalent value
added, as the annual assessment work for the assessment year ending September 1,
for the following contiguous
unpatented mining claim(s), located in the County of
, in the State of
.
BLM Serial No. Name of Claim
Tp Rg Sec Mer
County Recordation
Book and Page No.
Co. Recording
Date
Example: 13N 5E 14 MDM
(Continued on Page 2)
(Form 3830-004)
Save
Print
Clear
2.
Type of labor and improvements (specify what was done and give the total value for that labor and improvement to show at least
$100 for each claim). If a geological, geochemical, or geophysical survey was performed, as per 30 U.S.C. 28-1, reference the title
of the report of survey, give cost and date of the survey and report, and indicate it was filed with the County Recorder:
Description of Work Performed
Value of Work
Performed
Date Work Was
Performed
3.
Name and mailing address of each person who performed the labor and improvements:
Name (please print) Current Mailing Address (please print)
4.
Name and mailing address of each person who holds and claims the subject mining claim(s) for the valuable minerals contained
therein. Be sure to indicate if there is a change of address:
Name (please print) Current Mailing Address (please print)
5.
The undersigned testifies that on the date of , 20
, all monuments required by law
were erected upon the subject claim(s), and all notices required by law were posted on the subject claim(s) or copies thereof were
in place, and at said date, each corner monument bore or contained markings sufficient to appropriately designate the corner of the
claim to which it pertains and the name of the claim(s).
(Continued on Page 3)
(Form 3830-004, Page 2)
I hereby certify under penalty of perjury under the laws of the State of that the foregoing statements
are true and correct:
Date:
(Signature of person responsible for above statement)
Title 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, ctitious or fraudulent statements or representations as to any matter within its jurisdiction.
SUBSCRIBED AND SWORN TO before me, this
Notary Block
day of 20
By:
(Signature of Affiant)
Title:
My Commission Expires:
INSTRUCTIONS
1. This is an optional form that may be used to satisfy the requirements for the Bureau of Land Management (BLM) under the pro-
visions of 43 U.S.C. §1744 and 30 U.S.C. §28-28d and the regulations thereunder (43 CFR part 3835). Since local and State laws
may vary, you should contact your local and State agencies where the claims are located to ensure all applicable laws and require-
ments are satisfied.
2. The claimant(s) must fill in the date in paragraph 1 for the applicable assessment year and the county and state where the claims
are located.
3. All claim names and BLM serial numbers for which this assessment affidavit applies must be listed. Additionally, legal descrip-
tions, and original county recording information may be listed for additional identification purposes.
4. The claimant(s) must complete paragraph 2 listing all labor or improvements which was performed on or did benefit the subject
mining claims. The value and date of the labor or improvements must also be listed. The total amount of labor or improvements
can be listed, but the total expenditure must equal at least $100 for each claim.
5. The names and current mailing addresses of the person(s) performing the labor must be listed in paragraph 3.
6. The name and current mailing address of each owner (claimant) of the claims must be listed in paragraph 4. The mailing address
shall be the owner’s address and not the address of an agent or anyone representing the claimant. Be sure to note if there has been
a change of address.
7. Paragraph 5 shall be completed to show the date it was verified that all monuments required by law were properly erected, all
notices were posted, and that corners were appropriately designated for all claims listed.
8. An exact legible reproduction or duplicate (other than microfilm or other electronic media) of this affidavit or another type of
affidavit of assessment work that you file or will file in the county where each claim is located, must be filed with the BLM on or
before December 30 of the calendar year in which the assessment year ends. For mill or tunnel sites, a separate notice of intent to
hold must be filed with the BLM on or before December 30. Requirements for filing a notice of intent to hold can be found at 43
CFR 3835.33.
9. A processing fee of $15 for each claim listed must be remitted to the BLM along with this or any other affidavit of assessment
work.
(Continued on Page 4)
(Form 3830-004, Page 3)
click to sign
signature
click to edit
click to sign
signature
click to edit
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: 30 U.S.C. §28-28d 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 document compliance with 43 U.S.C. 1744 and that
assessment work has been completed in accordance with 30 U.S.C. § 28-28d and 43 CFR part 3835 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 2.231(b) and (c).
EFFECT OF NOT PROVIDING INFORMATION: Disclosure of the requested information is required by 30 U.S.C. § 28-28d and
43 CFR part 3835 for claimants qualified to perform assessment work in lieu of paying the maintenance fee. 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
assessment work information, which may result in forfeiture of the mining claim(s) by the claimant.
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 inform you that:
Use of this form is optional. You must perform assessment if a waiver to pay the maintenance fee has been requested. This form is provided
to help you attest that annual assessment work has been completed in lieu of paying the maintenance fee for your claim(s). 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 valid OMB control
number.
BURDEN HOURS STATEMENT: The estimated public reporting burden for this form is 30 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 Street, N.W., Room 2134LM, Washington, D.C. 20240.
(Form 3830-004, Page 4)
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

FORM APPROVED: AFFIDAVIT OF ANNUAL ASSESSMENT WORK (Bureau of Land Management - Main Domain)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 19 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document