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(Owner’s Name -Please Print) (Owner’s Original Signature)
(Owner’s Mailing Address) (City) (State) (Zip Code)
(Owner’s Name -Please Print)
(Owner’s Mailing Address)
(Owner’s Original Signature)
(City) (State) (Zip Code)
(Owner’s Name -Please Print)
(Owner’s Mailing Address)
(Owner’s Name -Please Print)
(Owner’s Mailing Address)
(Owner’s Original Signature)
(City) (State) (Zip Code)
(Owner’s Original Signature)
(City) (State) (Zip Code)
18 U.S.C. 1001 and 43 U.S.C. 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.
INSTRUCTIONS
1. This certication is made under the provisions of 43 U.S.C. § 1744 and 30 U.S.C. §28-28k and the regulations thereunder (43 CFR Part 3830).
2. The claimant(s) must ll in the years in paragraph 1 for the beginning and ending of the assessment year for which this waiver is sought. For example, if
the deadline for ling the waiver is September 1, 2020, it is for the 2021 assessment year and the assessment year’s beginning date is September 1, 2020
and its ending date is September 1, 2021.
3. The claimant(s) must ll in the year in paragraph 2 for the beginning of the assessment year for which this waiver is sought. This is the same year as ex-
plained in Instruction 2 above. This certies that the claimant(s) and their related parties owned 10 or fewer claims and sites nationwide as of that date. In
order for the waiver to be valid for the entire assessment year, all claimants must not own more than 10 claims and sites for the entire assessment year. If
any of the claimants own more than 10 claims and sites during the assessment year, the waiver will become void, and the maintenance fee for the assess-
ment year the claims and sites were under waiver will become due by the next September 1.
4. All claim and site names and BLM serial numbers must be listed for the mining claims, mill sites, and tunnel sites for which the waiver is sought.
5. All owners of the mining claims, mill sites, and tunnel sites and their addresses must be lled in, even if a designated agent is signing the form on behalf
of any of the owners.
6. This waiver form must be signed by all the claimants or their designated agent, in original form. If an agent is designated, a notarized designation of agent,
signed by all of the claimants with proper address given, must be submitted with this waiver. Agents sign their own names in place of the owner’s signa-
ture, and the agent’s signature must be in original form.
7. This form must be led no later than September 1st for the upcoming assessment year in the BLM State Oce where the mining claims or sites are re-
corded, or the waiver cannot be granted by the BLM. (Example: To obtain a waiver for the assessment year 2021, which begins on September 1, 2020, you
must qualify for and le for a waiver no later than September 1, 2020, in the proper BLM State Oce.)
8. You must le a notice of intent to hold by the December 30th immediately following the ling of this waiver. For example, if you le this waiver on Au-
gust 3, 2020, you must le a notice of intent to hold for the claims and sites listed on this form with BLM by December 30, 2020.
9. For all mining claims which require assessment work, you must le an adavit of assessment work with BLM on or before the December 30th immedi-
ately following the end of the assessment year for which this waiver was led. For example, if you led this waiver on or before September 1, 2020 for the
2021 assessment year, you must le an adavit of labor for the claims listed on this waiver by December 30, 2021. You must make this ling even if you
pay the maintenance fee for the next assessment year. For example, you led this waiver for the 2021 assessment year that ends September 1, 2021, and
paid the maintenance fee for the 2022 assessment year on September 1, 2021. You would still be required to le an adavit of assessment work for the
2021 assessment year by December 30, 2021.
10. For mill and tunnel sites, a notice of intent to hold for these sites is required to be led by the December 30th following the end of the assessment year for
which this waiver was led.
(Continued on page 3) (Form 3830-2, page 2)
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