INSTRUCTIONS
1. This is an optional form that may be used to satisfy the requirements for the Bureau of Land Management (BLM) under the provisions
of 43 U.S.C. §1744 and 30 U.S.C. §28f and the regulations thereunder (43 CFR part 3834). Since local and State laws may vary, you
should contact your local and State agencies where the claims are located to ensure all applicable laws and requirements are satised.
2. This form should be used to pay the maintenance fee for lode mining claims, mill sites, and tunnel sites only. To pay the maintenance
fee for placer mining claims, use Form 3830-5a.
3. Complete the section for the number of claims and the amount being remitted to the BLM.
4. Enter the year in paragraph 2 for the applicable assessment year.
5. List all mining claim or site names and the BLM serial number associated to the claim or site, if the BLM has notied you what the serial
number is. Every attempt should be made to include the current BLM serial number for each claim or site listed.
6. The name and current mailing addresses of the person paying the maintenance fee(s) should be listed at the top of the form. If this is a
change of address for a claimant, that should also be noted.
7. If needed, an additional sheet can be used to continue listing claim and site names and BLM serial numbers, or the name and current
mailing address of additional claimants.
8. If paying by credit card, you must complete the following credit card information on page 3: (a) exact name on the face of the credit
card; (b) amount paid; (c) type of card; (d) credit card number; (e) expiration date of the card; and (f) telephone number. You must also
sign on page 3 to show authorization to charge the credit card.
NOTICES
THE PRIVACY ACT and 43 CFR 2.48(d) require that you be furnished with the following information in connection with the
information requested by this form.
AUTHORITY: 30 U.S.C. 28f and 43 CFR part 3834 permit collection of the information requested by this form.
PRINCIPAL PURPOSE: The BLM will use the information you provide to record the annual maintenance fee payment for the claims
and sites listed and to verify that payment has been made in accordance with 30 U.S.C. 28f and 43 CFR part 3834.
ROUTINE USES: The BLM will only disclose this information in accordance with the provisions at 43 CFR 2.56(b) and (c).
EFFECT OF NOT PROVIDING INFORMATION: Disclosure of the requested information is required by 30 U.S.C. 28f and 43 CFR
part 3834 for claimants paying the annual maintenance fee. The use of this specic form when paying the maintenance fee is optional.
However, when paying the maintenance fee, it is the requested information on this form that is required to be submitted along with the fee.
Failure to submit all the required information will delay the BLM’s processing of the information and may preclude the BLM’s acceptance
of the maintenance fee payment, which may result in forfeiture of the mining claim(s) or site(s) by the claimant.
(Continued on Page 3)
(Form 3830-5, Page 2)
