Fillable OMB # 1029-0119 Expiration Date: 10/31/2021 ABANDONED MINE (Office of Surface Mining)

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OMB # 1029-0119 Expiration Date: 10/31/2021 ABANDONED MINE (Office of Surface Mining)

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U.S.A. forms for Office of Surface Mining

BROWSE OFFICE OF SURFACE MINING (DC) FORMS

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OMB # 1029-0119
Expiration Date: 10/31/2021
ABANDONED MINE LANDS (AML) CONTRACTOR INFORMATION FORM
You must complete this form for your AML contracting officer to request an eligibility evaluation from the
Office of Surface Mining Reclamation and Enforcement (OSMRE) to determine if you are eligible to receive an
AML contract. This requirement applies to contractors and their sub-contractors and can be found under
OSMRE’s regulations at 30 CFR 874.16. NOTE: This form must be signed and dated within 30 days of
submission to be considered for a current bid.
Part A: General Information
Business Name: _______________________________________________________________
Tax ID #: _______________________________________________________________
Address: __________________________________________________________
City, State, & Zip: __________________________________________________________
Phone Number: __________________________________________________________
Email Address: __________________________________________________________
Part B: Obtain an Organizational Family Tree (OFT) from the Applicant Violator System (AVS)
If you plan to certify the existing AVS information or submit updates under Part C, you must include an OFT.
To obtain an OFT, you may contact the AVS Office at 800-643-9748 or from the AVS website at:
https://avss.osmre.gov/. Instructions for how to download an OFT from the AVS can be found at:
https://www.osmre.gov/programs/AVS/aml-instructions.pdf.
Part C: Certifying and updating information in the AVS
Select only one of the following options, follow the instructions for that option, and sign and date below.
I, _________________________________________, have express authority to certify that:
(Print Name)
1. Our business is in the AVS and is accurate, complete, and up-to-date. If you select this option, you must
attach an Entity OFT from the AVS to this form. Do not complete Part D.
2. Our business is in the AVS but needs to be updated. If you select this option you must attach an Entity
OFT from the AVS to this form. Use Part D to provide the missing or corrected information.
3. Our business is not in the AVS and needs to be added. Complete Part D.
___________ _____________________ ________________
Date Signature Title
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OMB # 1029-0119
Expiration Date: 10/31/2021
Part D: OFT Information
Contractor’s Business Name: _____________________________________
If the current Entity OFT information for your business is incomplete in the AVS, or if there is no information
in the AVS for your business, you must provide all of the following information as it applies to your business.
Please include additional copies of this page if the space below is not sufficient to capture all information.
• Every officer (President, Vice President, Secretary, Treasurer, etc.);
• All Directors, Partners, and Members;
• All persons performing a function similar to a Director;
• Every person or business that owns 10% or more of the voting stock in your business;
• Any other person(s) who has the ability to determine the manner in which the AML reclamation
project is
being conducted.
• Please list an end date for any person no longer with your business.
Name: __________________________
Address: __________________________
Begin Date: __________________________
End Date: __________________________
% Ownership: __________________________
Position/Title: __________________________
Phone Number: __________________________
Name: __________________________
Address: __________________________
Begin Date: __________________________
End Date: __________________________
% Ownership: __________________________
Position/Title: __________________________
Phone Number: __________________________
Name: __________________________
Address: __________________________
Begin Date: __________________________
End Date: __________________________
% Ownership: __________________________
Position/Title: __________________________
Phone Number: __________________________
Name: __________________________
Address: __________________________
Begin Date: __________________________
End Date: __________________________
% Ownership: __________________________
Position/Title: __________________________
Phone Number: __________________________
PAPERWORK REDUCTION STATEMENT
The Paperwork Reduction Act of 1995 (44 U.S.C 3501) requires us to inform you that: Federal Agencies may
not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays
a current valid OMB control number. This information is necessary for all successful bidders prior to the
distribution of AML funds, and is required to obtain a benefit.
Public reporting burden for this form is estimated to range from 15 minutes to one hour, with an average of 30
minutes per response, including time for reviewing instructions, gather and maintaining data, and completing
and reviewing the form. You may direct comments regarding the burden estimate or any other aspect of this
form to the Information Collection Clearance Officer, Office of Surface Mining Reclamation and Enforcement,
1849 C Street, NW, Room 4559, Washington, DC 20240.
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OMB 1029-0119 Expiration Date: 10312021 ABANDONED MINE (Office of Surface Mining)

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Completed 19 July 2020

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