Form 3809-4a
January 2017)
No. 1004-0194 Expires:
January 31, 2020
In consideration for this rider and the acceptance of this rider by the Bureau of Land Management (BLM) on behalf of the United States of
America, this rider attaches to and is part of Surface Management Bond No. issued on behalf of
principal, in favor of the United States. The bond provides coverage as shown below:
; Statewide
; Nationwide
(Enter “Yes”, if applicable)
(Enter State Name, if applicable)
(Enter BLM Serial No.)
Increase/Decrease in Dollar Amount of Bond Coverage
It is understood and agreed that , principal, is increasing/decreasing the
coverage of this bond to the amount shown below; however, this rider will not act to increase/decrease the actual cumulative or potential
liability above the face amount of the bond, to wit:
U.S. dollars ($
Statewide/Nationwide Bond
The principal hereby agrees to and extends bond coverage to include any and all operations under 43 CFR 3802 and 43 CFR 3809.
Include name of State if coverage is Statewide
Bond Coverage Extended
The principal hereby agrees to and extends bond coverage to include notice-level operations pursuant to regulations at 43 CFR 3809.
Third Party Posting of the Financial Instrument for the Bond
It is understood and agreed that
is pledging the nancial instrument
to secure the attached bond on behalf of
, operator and principal on the bond.
It is understood and agreed that
, principal, is extending the coverage of the
bond referenced above to include liabilities for operations conducted by
on notice/plan of
operations serialized
(Continued on page 2)
This coverage of obligations will continue whether or not a notice/plan of operations has subsequently been suspended or terminated. This
rider will not act to increase the actual cumulative or potential liability of the principal or bond above the face amount of the bond. Nothing
herein contained will vary, alter, or extend any provision or condition of this bond except as herein expressly stated.
Executed this
day of
, 20
(Business Address)
(TIN or SSN, if applicable)
State of County of
Subscribed and sworn to before me this
(My Commission Expires)
(Notary Public)
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 benet. Failure to
disclose this information may result in BLM’s rejection of your application.
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 benet.
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 Ofcer (WO-630), 1849 C Street, N.W., Room 2134LM,Washington, D.C. 20240.
(Form 3809-4a, page 2)