Form 3504-4
(Aug 2016)
OMB NO. 1004-0121
Expires: August 31, 2019
Know All Men By These Presents, That
of ,
as obligor, is held and rmly bound unto the United States in the sum of
dollars ($ ), lawful money of the United States, to be paid to the United States, for the use and benet of (1)
the United States and (2) any owner of a portion of the land subject to the coverage of this bond, who has a statutory right to compensation
in connection with a reservation of the above-mentioned deposits to the United States. For such payment, well and truly to be made, he binds
himself, his heirs, executors, administrators, and successors, jointly and severally, by these presents.
That said Obligor, in order to more fully secure the United States in the payment of the aforesaid sum, hereby pledges as security therefor
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 demoninations
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.
If amount of this bond is $75,000, or if it is raised by an attached rider to that amount, coverage must extend to all obligors holdings involv-
ing deposits in the United States, including Alaska, under the act or acts cited in Schedule A.
If amount of this bond is $25,000, its coverage extends only to obligors holdings involving
deposits in the State named under the act or acts cited in Schedule A.
Public Domain Leasing Act of February 25, 1920
(30 U.S.C. Sec. 181)
Names of States
That conditions of the foregoing obligations are such that, whereas
the said obligor, in one or more of the following ways, has an inter-
est in mineral permits or leases issued under the act or acts cited in
Schedule A of this bond:
1. as permittee or as lessee;
2. as the approved holder of operating rights in all or part of the
lands covered by permits or leases under operating agreements with
the lessees; and
Acquired Lands Leasing Act of August 7, 1947
(30 U.S.C. Sec. 351)
Names of States
3. as designated operator or agent under permits or leases pending
approval of an assignment or operating agreement; and
Whereas the obligor is authorized to drill for, mine, extract, remove,
and dispose of the named mineral deposits in or under the lands cov-
ered by the permits, leases, operating agreements or designations, and
is obligated to comply with certain convenants and agreements set
forth in such instruments; and
(Continued on page 2)
(Form 3504-4, page 1)
Whereas the obligor agrees that the coverage of this bond, in addition
to the present holdings of the obligor must extend to and include:
1. Any mineral permit or lease hereafter issued to, or acquired by,
the obligor affecting the named mineral deposits in the State or States
now named in Schedule A, or later named in a rider, the coverage to
be conned in the obligors holdings under the act or acts cited at
the head of the column in which the name(s) of the State or States
appears and to become effective immediately upon such issuance or
upon departmental approval of a transfer in favor of the obligor.
2. Any operating agreement hereafter entered into or acquired by
the obligor, affecting the named mineral deposits in the States now
named in Schedule A, or later named in a rider, relating to mineral
permits or leases issued under the act or acts cited in Schedule A
at the head of the column in which the name of the State is placed.
The coverage must become effective immediately upon departmental
approval of the agreement or of a transfer of an operating agreement
to the obligor.
3. Any designation subsequent hereto of the obligor as operator or
agent of a permittee or lessee under a permit or lease issued pursuant
to an act or acts cited in Schedule A and covering lands in a State
named in Schedule A, either presently or by rider. This coverage must
become effective immediately upon the ling of such a designation
under a permit or lease.
4. Any extension of a permit or lease covered by this bond, such
coverage to continue without any interruption due to the expiration of
the term set forth in the permit or lease.
Whereas the obligor hereby agrees that notwithstanding the termina-
tion of any permit or permits, lease or leases, operating agreements
or designations as operator or agent, covered by this bond, whether
the termination is by operation of law or otherwise, the bond must
remain in full force and effect as to any remaining permits, leases,
operating agreements, or designations covered by the bond; and
Whereas the obligor as to any permit or lease or part of a permit or
lease for lands as to which he has been designated as operator or
agent, or approved as operator, in consideration of being permitted
to furnish this bond in lieu of the permittees or lessees, agrees and by
these presents does hereby bind himself to fulll, on behalf of each
permittee or lessee, all the obligations of each permit or lease for the
entire permit or lease areas in the same manner and to the same extent
as though he were the permittee or lessee; and
Signed on this day of , 20
(Signature of Witness)
(Printed Name of Witness)
(Address of Witness)
(Signature of Witness) (Printed Name of Witness)
(Address of Witness)
Whereas the obligor agrees that notwithstanding any use of the se-
curity pledged herewith for the purpose for which it is pledged, the
bond must remain in full force and effect in the sum above set forth
and that he will, whenever so required by the United States, deposit
additional security to bring the security up to the full amount; and
Whereas the obligor agrees that the neglect or forbearance of the
United States in enforcing, as against the permittees or lessees of the
United States, the payment of rentals or royalties or the performance
of any other convenant, condition, or agreement of the permits or
leases, must not, in any way, release the obligor from any liability
under this bond; and
Whereas the obligor agrees that in the event of any default under the
permits or leases, the United States may commence and prosecute
any claim, suit, action, or other proceeding against the obligor with-
out the necessity of joining the permittees or lessees.
Now, Therefore, If said obligor must in all respects faithfully comply
with all of the provisions of the permits and leases referred to herein-
before, then the above obligations are to be void; otherwise to remain
in full force and effect.
That the said obligor does hereby constitute and appoint the Secre-
tary of the Interior as his attorney, for him and his name to collect
or to sell, assign, and transfer the said United States bonds above
described and deposited by the obligor, as aforesaid, pursuant to au-
thority 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 condi-
tions and stipulations of such undertaking the said attorney will have
full power to collect said bonds or any part thereof, or to sell, and
transfer said bonds or any part thereof without notice, at public or
private sale, free from any equity or redemption or without appraise-
ment 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 performance of any of the con-
ditions 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 will
do by virtue of these presents.
, in the presence of:
(Signature of Obligor)
(Printed Name of Obligor)
(Business Address of Obligor)
If this bond is executed by a corporation, it must bear the seal of such corporation.
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 department 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 3504-4, 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: 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 on all your leases held within a State, or nationwide.
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 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 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 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 3504-4, page 3)