Form 3809-4
(
January 2017)
Form for Bond Rider Extending Coverage of Bond to Assume Liabilities for
Operations Conducted by Parties Other Than the Principal
(Consent of Surety)
RIDER
UNITED STATES
DEPARTMENT OF THE INTERIOR
BUREAU OF LAND MANAGEMENT
FORM APPROVED OMB
No. 1004-0194
Expires:
January 31, 2020
BLM Bond Number
Surety Bond Number
The principal and surety (or principal/obligor, if a personal bond) hereby agree to extend the coverage of the bond referenced above to include liabilities
for operations conducted by
on
plan/notice serial number
State of
(Name of Mine/Operation).
in which the principal holds interest or in the
(Statewide bond) or Nationwide (Nationwide bond).
Coverage includes the faithful performance of all plan of operations or notice level operations, both past and future, including the
responsibility for all surface reclamation, as led or approved by the Bureau of Land Management (BLM).
This coverage of plan of operations or notice level operations, will continue whether or not the plan(s) and/or notice(s) subsequently
expire, terminate, are abandoned, suspended or revoked; provided however, that this rider will not act to increase the actual cumulative
or potential liability for the surety above the face amount of the bond (penal sum).
, 20 .
day of
Surety
By
(Print Name)
Executed this
Principal
By
Attorney-in-fact
Business Address
Signature
Title
Business Address
(TIN or SSN)
This bond must bear the seal of the surety company, if a surety bond. If this bond is signed by a corporation, it should bear the seal
of the corporation, if applicable.
(TIN or SSN, if applicable)
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.
The Privacy Act of 1974 and the regulation in 43 CFR 2.48(d) require that you be furnished the following information in connection with information
required by this application.
AUTHORITY: 30 U.S.C. 22 et seq.; 43 U.S.C. 1732(b) and 1782(c); 31 U.S.C. 9301 et seq.; 43 CFR 3802 and 3809.
PRINCIPAL PURPOSE: Information is being used to establish nancial responsibility for surface disturbance on public lands.
ROUTINE USES: BLM will only disclose the information according to the regulations at 43 CFR 2.56(d).
EFFECT OF NOT PROVIDING INFORMATION: Disclosure of the information is necessary to obtain or retain a benet. Failure to disclose this
information may result in BLM’s rejection of your application.
NOTICES
The Paperwork Reduction Act of 1995 requires us to inform you that:
The BLM collects this information to grant the right to conduct exploration and mining activities on public lands.
Response to this request is required to obtain or retain a benet.
The 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 8 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 (1004-0194), Bureau Information Collection Clearance Ofcer (WO-630),
1849 C Street, N.W., Room 2134LM, Washington, D.C. 20240.
(Print Name)
(Print Name)
click to sign
signature
click to edit
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