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United States Department of the Interior

Office of Surface Mining Reclamation and Enforcement

**[GENERAL PURPOSE RIDER FOR SURETY BOND]{.underline}**

Permit No. \_\_\_\_\_\_\_\_\_\_\_\_\_ Bond No.\_\_\_\_\_\_\_\_\_\_\_

To be attached to and form a part of Surety Company Bond
No.\_\_\_\_\_\_\_\_\_\_\_\_\_\_ written by
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
AS SURETY, on behalf of

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_AS
PRINCIPAL, in the sum of
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_DOLLARS
(\$\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_), in favor of the United States
Department of the Interior, Office of Surface Mining Reclamation and
Enforcement (OSM) and executed on \_\_\_\_\_day,
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_, 20\_\_\_\_\_.

Whereas, OSM issued Permit No.\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_, dated
on\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ and Permit Renewals and Revisions
numbered and dated:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

pursuant to the application of the Principal;

Whereas, said bond and rider shall cover any and all land affected or to
be affected by the mining operation under the above mentioned permit and
revisions and renewals since the date of the issuance of the permit;

Now, therefore, the purpose of this rider is:

It is further understood and agreed that all other terms and conditions
of this bond shall remain unchanged.

**[PRINCIPAL]{.underline}**

Signed and executed this \_\_\_\_\_\_\_ day of
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_, 20\_\_\_\_.

BY:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
(Affix Seal)

TITLE:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

State of \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_)

) SS.

County of \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_)

**ACKNOWLEDGEMENT**

The foregoing instrument was acknowledged before me by
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

this \_\_\_\_\_\_\_ day of
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_, 20\_\_\_\_\_.

Witness my hand and official seal.
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

(Notary Public or other authorized officer)

My Commission Expires:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**[SURETY]{.underline}**

Signed and executed this \_\_\_\_\_\_ day of
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_, 20\_\_\_\_\_.

BY:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
(Affix Seal)

TITLE:

State of \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_)

) SS.

County of \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_)

**ACKNOWLEDGEMENT**

The foregoing instrument was acknowledged before me by
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

this \_\_\_\_\_\_\_ day of
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_, 20\_\_\_\_\_\_.

Witness my hand and official seal.
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

(Notary Public or other authorized officer)

My Commission Expires:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**[RESIDENT AGENT FOR SERVICE]{.underline}**

Resident Agent:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

(Signature)

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

(Printed Name)

Address:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**ACKNOWLEDGEMENT**

The foregoing instrument was acknowledged before me
by\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

This \_\_\_\_\_\_\_\_ day of
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_, 20\_\_\_\_\_.

Witness my hand and official seal.
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

(Notary Public or other authorized officer)

My Commission Expires: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Paperwork Reduction Act Notice

We use the information required by this form to ensure that the
requirements in 30 CFR Part 800.20 continue to be met as conditions
change. You must provide the requested information to obtain a benefit
(continuation of a surety bond). Under 30 CFR 842.16, the information
collected is a matter of public record.

The time needed to complete this form and submit the requested
information will vary depending on individual circumstances. We estimate
that the average time will be one hour per response. This number
includes the time spent reviewing instructions, learning about the
regulations, gathering and maintaining information, and completing and
reviewing the form. If you have comments concerning the accuracy of this
estimate or suggestions for simplifying the form or instructions, you
may write to the Information Collection Clearance Officer, Office of
Surface Mining Reclamation and Enforcement, Room 202 SIB, 1951
Constitution Ave, NW, Washington, D.C. 20240.

Under the Paperwork Reduction Act of 1995 (44 U.S.C. 3501 et seq.), you
are not required to respond to, nor will you be subject to a penalty for
a failure to comply with, a collection of information unless it displays
a currently valid OMB control number.

OMB Control No. 1029-0043; expires 1/31/2009