Form 3504-3
(Aug 2016)
(Continued on page 2)
OMB NO. 1004-0029
Expires: August 31, 2019
(Form 3504-3, page 1)
Serial Number
Bond Number
Know All Men By These Presents, That
of , as principal,
of , as surety,
are held and rmly bound unto the United States in the sum of
($ ), lawful money of the United States, for the payment of which, well and truly to be made, we bind ourselves,
and each of us, and each of our heirs, executors, administrators, and successors, jointly and severally, rmly by these presents
The conditions of this obligation are such, that whereas the said principal entered into a lease of the lands described therein and upon condi-
tions therein expressed, which lease bears the above serial number.
Now, Therefore, if the said principal, his heirs, executors, administrators, or successors, will faithfully carry out the obligations and observe
the requirements of said lease, and will duly keep, perform, and abide by each and every term and provision of said lease as therein stipulated
and agreed, then this obligation will be null and void; otherwise to remain in full force and effect.
Signed on this day of , 20 , in the presence of:
(Signature of Witness) (Printed Name of Witness)
(Address of Witness)
(Signature of Witness) (Printed Name of Witness)
(Address of Witness)
(Signature of Witness) (Printed Name of Witness)
(Address of Witness)
(Signature of Principal) (Printed Name of Signer)
(Address of Principal)
(Signature of Surety) (Printed Name of Signer)
(Address of Surety)
(Signature of Surety) (Printed Name of Signer)
(Address of Surety)
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
* This form of bond may be used in connection with coal, phosphate, and sodium leases, Act of February 25, 1920, as amended (30 U.S.C. 181 et seq.);
potassium leases, Act of February 7, 1927, as amended (30 U.S.C. 281 et seq.); sulphur leases, Act of April 17, 1926, as amended (30 U.S.C. 271 et seq.); all
such leases involving acquired lands, Act of August 7, 1947 (30 U.S.C. 351), and asphalt leases, Act of June 28, 1944 (58 Stat. 463, 483-485), by inserting
the particular mineral applicable in the space provided therefore. If this bond is executed by a corporation, it must bear the corporate seal.
(Form 3504-3, 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 CFR Parts 3400 and 3500
PRINCIPAL PURPOSE: The 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.
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 a mineral lease
The Paperwork Reduction Act of 1995 requires us to inform you that:
BLM collects this information to comply with the regulations at 43 CFR Parts 3400 and 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
BLM uses the information to protect the interests of the United States in cases where lessees fail to perform under the terms, conditions, and
stipulations of their mineral leases.
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.