Form 3504-1
(Aug 2016)
OMB NO. 1004-0121
Expires: August 31, 2019
Serial Number
Bond Number
Know All Men By These Presents, That
, as obligor, is held and
rmly bound unto the United States in the sum of dollars,
($ ), lawful money of the United States, for the payment of which, well and truly to be made, he binds himself,
his heirs, executors, administrators, and successors, jointly and severally, rmly by these presents.
The conditions of this obligation are such, that whereas the above-named obligor entered into a mineral lease or prospecting permit of the
lands described therein upon conditions therein expressed, which mineral lease or prospecting permit bears the above serial number.
Now, Therefore, if the said obligor, his heirs, executors, administrators, or successors, will faithfully carry out the obligations and observe
the requirements of said mineral lease or prospecting permit and will duly keep, perform, and abide by each and every term and provision
of said mineral lease or prospecting permit as therein stipulated and agreed, then this obligation will be null and void; otherwise to remain
in full force and effect.
That said obligor, in order the more fully to secure the United States in the payment of the aforesaid sum, hereby pledges cash as security
therefor or negotiable bonds of the United States, of a par value equal to the amount specied, which said bonds are numbered serially and
are in the denominations and amounts and are otherwise more particularly described as follows:
bonds of $
, bearing percent interest, with coupons attached to each numbered
which said bonds have been deposited with the Secretary of the Interior.
* This form of bond may be used in connection with phosphate, and sodium mineral leases or prospecting permits, Act of February 25, 1920, as amended
(30 U.S.C. 181 et seq.); potassium mineral leases or prospecting permits, Act of February 7, 1927, as amended (30 U.S.C. 281 et seq.); sulphur mineral
leases or prospecting permits, Act of April 17, 1926, as amended (30 U.S.C. 271 et seq.); all such mineral leases or prospecting permits involving acquired
lands, Act of August 7, 1947, (30 U.S.C. 351), and asphalt mineral leases or prospecting permits, Act of June 28, 1944, as amended (25 U.S.C. 561–562),
by inserting the particular mineral applicable in the space provided therefor. This form is for use where the mineral lease or prospecting permit covers either
public lands or lands embraced in an entry or patent subject to the reservation of potassium, phosphate, or sodium deposits to the United States under the Act
of July 17, 1914 (30 U.S.C. 121–123); pursuant to the Act of June 22, 1910 (30 U.S.C. 83–85), pursuant to the Act of March 8, 1922 (48 U.S.C. 376–377);
or of sulphur pursuant to the Act of March 4, 1933 (30 U.S.C. 124). If this bond is executed by a corporation, it must bear the corporate seal.
(Continued on page 2)
(Form 3504-1, page 1)
That the said obligor does hereby constitute and appoint the Secre-
tary of the Interior as his attorney, for him and in his name to collect
or to sell, assign, and transfer the said cash or United States bonds
above-described and deposited by the obligor, as aforesaid, pursuant
to authority conferred by section 1 of the Act of July 30, 1947 (61
Stat. 646; 6 U.S.C. 15), as security for the faithful performance of
any and all of the conditions or stipulations as hereinbefore set out,
and it is agreed that, in case of any default in the performance of
the conditions and stipulations of such undertaking the said attorney
must have full power to collect said bonds or any part thereof, or
to sell, assign, and transfer said bonds or any part thereof without
notice, at public or private sale, free from any equity of redemption
or without appraisement or valuation, notice and right to redeem
being waived, and to apply proceeds of such sale or collection to
the full amount of the bond to the satisfaction of any damages, or
deciencies arising by reason of such default, as said attorney may
deem best. The interest accruing upon said United States bonds
deposited as above stated, in the absence of any default in the per-
formance of any of the conditions or stipulations of the bond, must
be paid to said obligor. The said obligor hereby for himself, his
heirs, executors, administrators, and successors, raties and con-
rms whatever his said attorney must do by virtue of these presents.
Signed on this day of , 20 , in the presence of:
(Printed Name of Witness)
(Printed Name of Obligor)
(Signature of Witness)
Signature of Obligor)
(Address of Witness)
(Address of Obligor)
Title 18 U.S.C. Section 1001 and Title 43 U.S.C. Section 1212, make it a crime for any person knowingly and willfully to make to any de-
partment or agency of the United States any false, ctitious or fraudulent statements or representations as to any matter within its jurisdiction.
(Continued on page 3)
(Form 3504-1, page 2)
The Privacy Act of 1974 and the regulation in 43 CFR 2.48(d) provide that you be furnished with the following information in connection
with information required by this bond form.
AUTHORITY: 30 U.S.C. 181 et seq., 43 U.S.C. 3500
PRINCIPAL PURPOSE: Bureau of Land Management (BLM) will use the information you provide to ensure that the United States is fully
indemnied against failure to perform under the terms, conditions and stipulations of a mineral lease or prospecting permit.
ROUTINE USES: In accordance with the System of Records titled, “Land and Minerals Authorization Tracking System—Interior, LLM-
32,” disclosure outside the Department of the Interior may be made: (1) To appropriate Federal agencies when concurrence or supporting
information is required prior to granting or acquiring a right or interest in lands or resources, (2) To Federal, State, or local agencies or
a member of the general public in response to a specic request for pertinent information, (3) To the U.S. Department of Justice or in a
proceeding before a court or adjudicative body when (a) the United States, the Department of the Interior, a component of the Department, or
when represented by the government, an employee of the Department is a party to litigation or anticipated litigation or has an interest in such
litigation, and (b) the Department of the Interior determines that the disclosure is relevant or necessary to the litigation and is compatible with
the purpose for which the records were compiled, (4) To an appropriate Federal, State, local, or foreign agency responsible for investigating,
prosecuting, enforcing, or implementing a statute, regulation, rule, or order, where the disclosing agency becomes aware of an indication of
a violation or potential violation of civil or criminal law or regulation, (5) To a member of Congress or a Congressional staff member from
the record of an individual in response to an inquiry made at the request of that individual, (6) To the Department of the Treasury to effect
payment to Federal, State, and local government agencies, nongovernmental organizations, and individuals, and (7) To individuals involved
in responding to a breach of Federal data. The BLM will only disclose this information in accordance with the Freedom of Information Act,
the Privacy Act, and the provision in 43 CFR 2.56(c).
EFFECT OF NOT PROVIDING INFORMATION: Filing of this information is required to obtain and keep a benet. If you do not provide
a bond, BLM will not issue you a prospecting permit or lease.
The Paperwork Reduction Act of 1995 requires us to inform you that:
BLM collects this information to comply with the regulations of 43 CFR 3500, which implement the provisions of the Mineral Leasing Act
of 1920, as amended; the Mineral Leasing Act for Acquired Land of 1947; and section 402 of Reorganization Plan No. 3 of 1946.
BLM uses the information to protect the interests of the United States in cases where lessees or permittees fail to perform under the terms,
conditions, and stipulations of their mineral leases or permits.
Response to this request is required to obtain and keep a benet.
BLM would like you to know that 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 4 hours per response, including the time
for reviewing instructions, gathering and maintaining data, and completing and reviewing the form. Direct comments regarding the burden
estimate or any other aspect of this form to: U.S. Department of the Interior, Bureau of Land Management (1004-0121), Bureau Information
Collection Clearance Ofcer (WO-630), 1849 C Street, N.W., Room 2134 LM, Washington, D.C. 20240.
(Form 3504-1, page 3)