DEPARTMENT OF THE 

a 

SYSTEM 

'or 

and fa~: 

services 

Program 

· and Enfo~ement (OSMRE) Directives: 

for SOAP Assistance~ (Chapter 43, Section 

93) dated May 18 1 1981, and ,;Laboratory 

(Chapter 43, section 20, Transmittal 

1.8, 1981. S_i~i:ficant prov-isions of this_ 

a. The use of data from the AML fee compliance system to 

verify production suhqitted by the applicant (para 4c(2) (d)3). 

b. _The use of data from the applicant violator system to 

verify ownership patterns (para 4c(2) (d)3], and to review the 

performance history of the applicant (para 4c(2{~}5). · 

c. The applicant can appeal the final agency decision on 

eligibilitY to the Interior Board of Land Appeals (para 4c(4)). 

d. · Procedures for selecting and contracting with qualified 

laboratories (para 4c(6)), 

e, A description of technical services authorized for the 

SOAP (para 3d) • 

J. . )MtiAiUou. 

b. 

who has 

and who 

The probable total amount of coal 

all ~ining operations owned by the 

consecutive 12-month period of the permit 

is being sought. 

Applicant. An individual, corporation, or partnership 

submitted an application for assistance through the SOAP 

intends to seek a SMCRA permit. 

total amount of 

consecutive 12-month 

or business entities 
having a financial interest in the applicant; 2) operations in 

which the applicant has a financial interest; 3) members o:r the 

applicant's familY or the applicant's relatives; and 4) 

operations owned by persons who control the applicant's 

operation, as prorated and discussed in detail at 30 CFR 795.6. 

d. ~~~~; Services for the collection and 

·o and geologicjoverburden analyses as 

are necessary to comply with appropriate requirements 

contained in 30 CFR 780,21 and .22 (for surface mines) and 30 CFR 

784,14 and .22 (tor underground mines). Costs for drilling 

observation wells necessary for the collection of ground water 

information are covered under the program; however, costs for 

overburden drilling to define the extent of the coal or for 

sampling overburden materials are not covered. In addition, 

engineering analysis or designs are not authorized services. 

Collection of data from local or regional sites in expectation of 

applications is not authorized under the program. 

An eligible applicant may receive complete services (all 

applicable hydrologic and geologic data normally associated with 

a new permit application) or partial services needed to correct 

permit deficiencies identified during the initial or mid-term 

permit review process. 

e. Control. An individual or business entity producing 

coal and having the authority to make policy decisions or 

otherwise direct the management of the applicant or applicant's 

operation. Indirect control of an applicant can be exercised by 

the terms and conditions specified in a contract mining agreement 

with another coal company. 

f. Program. Small Operator Assistance Program [SOAP) as 

authorized by Section 507(c) of SMCRA. 

g. Small operator. Any operator whose probable total 

production is between 250 tons and 100,000 tons of coal during 

any consecutive 12-month period. 

The sum of actual and 

~~~::':~~,; for any consecutive 12- month of the permit, or ~ each of the first five 

years the permit for which SOAP assistance is to be provided, 

whichever period is shorter. 

4. Poligy/Proce4gres. 

a. Policy. To receive SOAP assistance, an operator must 

offer proof of meeting the requirements outlined in JO cFR 795.7 

by submitting a complete application for assistance that can be 

evaluated and verified following the procedures in this 

directive. 

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b. Responsibilities. 

•nd '" 

SOAP. 

(2) The provide 

applications for information to 

potential applicants, render a final agency decision on each 

application for assistance, maintain records, and submit reports 

in accordance with the requirements of this directive. 

~~~;(3) The Assistant Director. Eastern or Western 

shall provide contract and technical support, as 

to the appropriate FOD. 

(4) The 

provide production 

FODs. 

. . (5) The 

provide i~;~fon'!lation 

·of appl-icants to 'the 

c. Procedurel!. 

(1) Glneral. The FODs shall send all necessary 

infon'llation and the approved application form (copy attached) to 

operators seeking assistance. To become eligible for assistance, 

operators must submit the completed application form with the 

required descriptive material and signed affidavits to the 

appropriate Field Office for revieW and evaluation. 

(2} Application Beview. 

(a) Recordkeeping. All applications shall be date 

stamped and recorded at the time of receipt and a record kept on 

the status of each application. 

Within 5 , FOD 

shall complete completeness in 

accordance with the requirements 30 CFR 795.7. If the 

application is com~lete, the FOD shall send written notification 

to the applicant w~thin 3 working days after the completeness 

review indicating that the application is complete and is under 

review for determination of eligibility. 

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deficiencies in the application. Field Office staff may help the· 

applicant correct minor deficiencies. 

evaluate the 

J. 

applicant is required to 

coal production for each 

The FOD shall 

i! Soureas ot Pro4uction. 

attributed production from the following sources will 

Actual and 

be counted: 

i) 

ations owned by the applicant. 

All coal produced by ope~-

ii) The pro rata share, based upon 

percentage of ownership, of coal produced by operations in which 

the applicant owns more than a 5 percent interest, or in which 

other operations own more than 5 percent of the applicant. 

iii) All coal produced by 

operations owned by persons who directly or ind+rectly control 

the applicant by reason of direction·of the management. 

iv) All coal produced by 

operations owned by members of the applicants' family and 

relatives, unless it is established there is no direct or 

indirect business relationship between or among them. 

Contract. Generally, if 

ownership, or apparent management control by a 

cont~act buyer, broker, or other coal company having a business 

relationship with the applicant, then production from these 

sources is not attributed to the applicant. Otherwise, 

attributed production under the conditions stated above is added 

to the actual production of the applicant. Agreements or 

contracts between the operator and a buyer, broker or other coal 

comvanies having a business relationship with the applicant 

e!J.ould be closely reviewed on a case-by-case basis to e.:sure 

compliance with 30 CFR 795.6. Some common business relationships 

that should be evaluated with respect to direct or indirect 

control and any resulting attributed production to the applicant 

include: 

i) Applicants brokering coal for 

other producers; 

ii) Applicants having agreements 

to mine coal for a broker, processor, or large company which owns 

or lea.:::as the coal and also has its own production; 

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iii) Applicants under contract to 

mine another owner's coal, and who purchase or lease equipment 

from or receive engineering assistance from that ownert and 

iv) Applicants who apply for and 

are responsible for the permit provisions but allow the buyer to 

post bond. 

An 

applicant's program is 

not on rates. However, these rates 

serve as of an applicant's production 

capability. Coal production for the year preceding the 

application is required in the application by 30 CFR 795.7, This 

production and ownership relationships that may result in 

attributed production shall be verified as explained below. The 

FOD shall also resolve any discrepancies between estimated 

production and past production. For example, assistance should 

be denied unless the applicant can demonstrate in writing that 

total production will be 100,000 tons per year or less, when 

total production during the preceding year was ~ubstantially 

greater than 100,000 tons. 

3 verification of Past Total Production 

Ratll and OWnership Patterns. 

production through production • 

Fee compliance System. 

The FOD shall 

data provided 

verify past 

by the Manager, AML 

Q The FOO shall verify ownership 

patterns {and any attributed production) through information 'in 

the applicant violator system which will be provided by the 

Chief, Division of Debt Management • 

.i Right to Mine and Right to Enter 

Documents. Right to mine documents normally are coal lease 

agreements and right to enter documents normally are related to 

surface rights. These documents should be current official 

documents and bear the name of the applicant. 

~ Pexformanoe "fliston. A review for 

unpaid civil penalties, unabated violations and delinquent 

reclamation fees must be conducted as a- part of the SOAP 

assistance eligibility evaluation. The FOD shall evaluate 

performance history and eligibility for a permit through 

information in the applicant violator system which will be 

provided by the Chief, Division of Debt Management, The 

performance history of both the applicant ~nd operator, if they 

are different entities, must be evaluated before approving SOAP 

assistance. 

' 
,i Eligible Operations. Sites where coal 

or coal reruse is to be mined and requires a permit in accordance 

with 30 CFR Part 780 or 784. operations incidental to coal 

mining such as tipples and processing plants, are not eligible. 

1 

will be denied if the 

unsuitable for mining, ;~::::i,!rtiti:n~ unsuitable for mining is 

'{3) Eligibility Deqision. An applicant shall be found 

eligible if (a) he/she demonstrates through the application the 

intent to apply for a permit pursuant to the Act; (b) he/she 

establishes through the application that the probable total 

actual and attributed production for each year of the permit will 

not exceed 100,000 tons; c) the applicant does not organize or 

reorganize his or her company solely for the purpose of obtaining 

SOAP assistance; and d) the FOD finds the applicant is not 

restricted in any manner from receiving a permit for mining in 

the area proposed. The FOD shall render a decision on 

eligibility within 10 working days of the date of the 

notification letter of completeness and notify the: apPJ_icant via 

certified .man within'-3 dayS after the deCision- On etigibiHty.- · The written notification of eligibility must contain statements 

that: {a) the applicant and any successor is liable for any 

contract costs should the Office of surrace Mining Reclamation 

and Enforcement have to cancel the project before it is 

completed; and (b) that production data contained in the AML Fee 

Compliance System will serve as the basis tor calculating total 

production once the applicant commences mining. 

the applicant oi: 

mail. The letter: 

(a) the reason for the ineligibility; 

(b) that a fin"'l agency decision will be rendered 

in 30 days from the date of the !utter; and 

(c) the applicant has the opportunity to respond 

in writing or request a meeting with the FOD within this 30 day 

period, if the applicant wishes to provide any other information 

that may have a direct bearing on the final agency decision. 

Following the 30 day period, the FOO will render a final agency 

decision considering any relevant information provided by the 

applicant. The final agency decision will declare either-

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1 the applicant is eligible based on 

information which showed the initial FOD finding to be based on 

inaccurate data, or 

~ the applicant is ineligible. Any final 

agency decision .ust be conveyed to the applicant in writing by 

certified ntail. For cases where the final decision finds the 

applicant ineligible, the letter shall contain: 

.!l a statement of the final agency 

decision and the reason{s) for the decision; 

Iii a statement that the decision is 

subject to administrative appeal to the Interior Board of Land 

Appeals and the following statement that describes the appeals 

procedure: 

"This decision may be appealed 

in accordance with the regulations 

found at 43 CFR 4.1.280 through 1286 

(copy attached). To initiate an 

appeal, you must file a written 

notice of appeal with this office 

at the above address within 20 days 

of the date you receive this 

decision. At the same time, you 

must also file a copy of the notice 

with the Interior Board of Land 

Appeals, 4015 Wilson Boulevard, 

Arlington, Virginia 22203. The 

IBLA will render a final agency 

decision on the matter in 

accordance with the applicable 

regulations. Failure to strictly 

comply with these requirements may 

result in summary dismissal of the 

appeal." 

(5) snhJoission of i§lse rntormation. Information in 

the application for assistance is assumed to be submitted in good 

faith. If the FOD learns that any of the information submitted 

in the application is false, the applicant shall be notified via 

certified mail of the allegation. The applicant shall be given 

the opportunity to either explain or refute the allegation of 

false information. If the applicant fails to resolve the 

allegation, then the assistance shall be denied and the FOD shall 

refer the matter to the Office of the Inspector General for 

appropriate action. 

(6) Coutraeting for Authorized Services. The FOD 

shall seek assistance, as appropriate, trorn the Assistant 

Director, Eastern or Western Field Operations with regard to 

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developing and issuing a Request for Proposal (RFP) solicitation, 

selecting a qualified laboratory under that solicitation, 

developing a site specific scope of work, designating a Technical 

Project Officer (TPO) to monitor the contract, and designating a 

contracting officer to administer the contract and pay invoices. 

Coordination shall be maintained with local Federal permitting 

personnel so that the site specific scope of work can be tailored 

exclusively to Federal permitting requirements and in the 

appropriate format for the requirements. 

Laboratory qualification shall bEl accomplished as part of the RFP 

process. The RFP shall contain criteria for determining a 

laboratory's qualification based upon criteria found at 30 CFR 

795.10 and unit cost criteria for selection of contractor based 

on lowest cost among 'those laboratories deemed technically 

qualified. 

(7) oversight of state Programs. This directive is 

not intended to serve as a basis for the oversight of state 

SOAPs. When evaluating a State's implementation of its approved 

regulatory program, OSMRE personnel shall adhere to all 

requirements and policies contained in that prograM. 

a. Name of applicant and company and ownership 

relationships, if applicable.-

b. Address and phone number of applicant. 

c. Date when application was received. 

d. Date when application was approved or rejected. 

e. Probable total annual production. 

f. 

county, 

Geographic location of proposed permit area (state, 

longitude, and latitude). 

g. Summary of assistance provided and contract costs for 

assistance. 

h. Qualified laboratory(s) that provided assistance. 

i. Date(s) that approved laboratory report(s) sent to 

applicant. 

This information shall be provided to the chief, Division of 

Technical Services b1• october 1 of each year. 

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The FOD shall provide a copy of the contract and final laboratory 

report(s) to the applicant using certified mail. Furthermore, 

the FOD shall provide the name and MSHA number for each applicant 

receiving final reports to the Manager, AML Fee compliance 

System. 

The Chief, Division of Debt Management, shall provide reports on 

performance history as available through the applicant violator 

system, in response to FOD requests. 

The Manager, AML Fee compliance System shall provide reports on 

coal sales as available through the Fee Compliance System, in 

response to FOD requests. 

6, Ef'f'ect on Other Doclllllents. 

a. Supersedes the following memoranda: 

July 23, 1985, memorandum signed by Director on 

"Small Operator Assistance Program Eligibility 

Applicant and Operator Violation History" 

May 24, 1983, memorandum signed by Assistant 

Director, Program Operations and Inspection, on "Small 

Operator Assistance Program -Update of List of 

Qualified Laboratories" 

March 12, 1985, memorandum signed by Acting 

AsSistant Director, Program -operations and Inspection, 

on "Role of the Small Operator Assistance Program in 

Correcting Permit Deficiencies" 

November 7, 1983, memorandum signed by Assistant 

Director, Program Operations and Inspection, on 

"Clarification on Reimbursement and Contract Mining 

Related to the Small Operator Assistance Program" 

March 29, 1983, memorandum signed by Assistant 

Director, Program Operations and Inspection, on "Coal 

Activities Eligible for Assistance in the Small 

Operator Assistance Program" 

December 30, 1982, memorandum signed by Assistance 

Director, Program Operations and Inspection, on 

"Eligibility of SOAP funding -Payment of Reclamation 

Fees" 

b. Supercedes Directives: "Operator Eligibility for SOAP 

Assistance" (Chapter 43, Section 10, Transmittal Number 93) dated 

May 18, 1981, and "Laboratory Qualification for SOAP" (Chapter 

43, section 20, Transmittal Number 94) dated May 18, 1981. 

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7, Bertrtna••· Section 507(c) of the Act, and 30 CFR Part 795. 

a. Ett•etive Date. Upon issuance, 

9. Contact. Chief, Division of Technical Services, 343-1480. 

10. X•y Words. SOAP, Eligibility Determination, Authorized 

Services. 

11. App•ndie~es. 

Small Operator Assistance Application. 
UNITED STATES DEPARTMENT OF THE INTERIOR 

OFFICE OF SURFACE MINING RECLAMATION AND ENFORCEMENT 

SMALL OPERATOR ASSISTANCE APPLICATION 

Date of Application: ____ _ 

A. BACKGROUND 

1. Permit Applicant's: 

Company Name 

Street Address 

City State Zip 

Autlwrized Company Official and Title 

(Area Code) and Phone No. 

2. Operiltor's nanJe and address, if different than applicant: 

3. Applicant is an ind'''""''"""'~''.:==::~o.;;;eo, (or) a part<·':'~'~'~h~;~p'.:====; (or) a corporation Date of formation_ 

4. Has applicant ever been denied Sma11 Operator Assistance? 

If yes, attach a fu11 explanation of the circumstances and 

denial. 

PAPERWORK REDUCTION ACT S'fATEMENT 

Yes No 

reasons for 

~ 

"lJte ~ El£duction Act of 19l:ll! (44 U:S.C 35) r<q"""s us 10 in[""">"" tbae l'lu> '"'""""""" " brlng wii«J<d in ordo ftK a of quaiific,.;, OJ IJ< ltU!&. l'lu> infrmnat""' MiliJ< -=1"' <in.,;,. app#caN's qu/JNfi=ioo. The obligation lo ~n</ 

" vohmJmy." 

Pub& npom.g bmdm fer t/u$ fO'"' i< "'""'"'d 11> """"'W ~[><' ""J""'S' '"'"'<W!g "'"'fer I'<Vhi»g Wtn.aion~ ga<h<nng and 

mainu.ining- ond «>mp/mllg ami ,..,.,.;..g IM fcrm. Di,r<r co"""""" rega~<W!g 11¥- """""" """"-" fll/oer aspecr of rm. form to W lnfomv>ticn Ccii«<WWo a...ron.:. Offk<r, Off"" "'Swfoc< Mining Reel""'"""" ond En~~ W<llhington, D.C ;:QUO; and 

Office of lnfbrmmiDn ami R<gulawryAf!.;,. Off«< of Ma"""""""' ond ~ w.wrwon. D.C. ::OS!JJ. 
SMAU. ASSISTANCC 

5. Has applicant ever had a Small Operator Assistance Project with either 

OSHRE or a State Regulatory Authority. Yes __ No __ . If yes, 

complete below: 

Pro teet Name Contractor 

OSifRE 

State " 

Date SOAP 

Reports 

Received 

8, PERMIT INFORMATION FOR pROPOSED ASSISTANCE SITE 

1. Is site currently permitted? Yes_ No __ . 

2. If permitted, give: Permit Number----- Issue _date ___ _ 

3. What are the il.nticipated starting and termination dates of the mining operation? From To __ _ 

a. Nl1m<l'------------

' """'"---------

c. Lmiw<k: -----------

e. Ltmginuk: --------

f. Name of!l~st .weam: --------

5. Hethod of Mining (check appr·opriate box): 

Ami Stripping ( ) MounMint<>p Rema.ai ( ) 

Deep M~ ( ) Au!"'' Operalioll ( ) 

Contour Sttippillg ( ) OW.· ( ) 

q othet'tk.<Ciibe: -------------

5. Number of acres in permit are~ (nearest tenth): --------

7. (a) Pmbablede[Xhofcoalresource: 

Average lkprh to coal Fur 

Maximum depth to coal Feel 

(b) Probabk lhiclatess of coal resouru<: 

Fat Inches ___ _ 

• 
• 

SMALL OPERATOR ASSISTANCE APPUCAT100 

(c) Are lhFJTe muJtipJe seams? Yes~ No __ 

If yes, B1fii.ch depfh and lhlckness Informal/on for each addiliornY seam. 

(d) Estimate of reserves in the permit at$11 and method of calcul811on.' 

8. State the projected production for each year of the permit area for 

which assistance is being sought. 

SOAP Site 

C. MAPS 

Provide U.S. Geological Survey topographical map of 1:24,000 scale or larger, 

or a topographic map of equivalent detail which clearly shows; 

(a) The lwwldaries of tM prof]Ofed pumU <UN tmd the IUllW'tll tirriitwge abo"' and below the 

affected area. 

(b) Propeny IK>undaries QTid The name of record for property <>Wiler.! within the permit area and 

adjace11t /Qnd. 

(~) The locati011 of exim"ng stnsctwo<< aNI devel<>ped water sowces wilhin lhe permit area and on 

adjac""f l<u!ds. 

(d) The locariOFI of exisling and proposed test borings or care sampling. 

(e) The location and «<tm! of hwWII workings of any underground mifll!s within the pe""it area 

and adjaunt area. 

D. DOCUMENIAJION 

Provide copies of documents which show that: 

1. The applicant has a legal right to enter and mine coal within the permit 

area; and 

2. A legal right of entry has been obtained for the Office of Surface 

Mining Reclamation and Enforcement and laboratory personnel to inspect 

the hnds to be mined and adjacent lands which may be affected, to 

collect environmental data, or to install monitoring equipment. 
I. 

SMALL OPERATOR ASSISTANCE APPUCAllON Pago..!._oi_L 

(•) 

,,, 

(<) 

,,, 

(<) 

E. 

All! Olher nrinu """'ed or operated l1y the llfJPlicunl? Yu _ N• _ 

~ tlu "''J''iaml rontrol ariY othtr mUle ("cOIIIrol" m......,., but is not limikJ to, di=:rioo of tlu~)1 Y01$_N,_ 

D<>e.< tJu "f'p/iCQilt"""' mare th!UI a ftvt per=l (5%) illte=t ill ""Y other coal mining 

opm#ionf Y<!::t_No_ 

D<>e.< ""Y pe:«m or~"""'"""" tiuu1 aftw percent (S%) illte=t in lh~ applkatU, ar 

tlbully m indilully C411trol the appr<CiOIIIt by tUSOlt of stock awnu.rhip, direction of the 

mmuJgtmmt, or in '""Y other nuttrnU whatsoever? Y~s _ No _ 

2. if any of thti above·:r{ve queStions (l(a), (b), (c), (d},·or (e)) are 

anSI'Iered "Yes", provide the information listed below for each coal 

mining operation operated during the past twelve (12) months. If 

question "(c)", "(d)" or "(e)" was answered "Yes•, the total and pro 

rata share of cual production must be furnished. List each mining 

operation separately and attach extra sheets as needed. 

(a) NameofCompany __________ _ 

llr111e LocaJioo (County)------'~' __ _ 

(c) Swface Miru: or Underground MiM Pmnit No. -------

(d) MESA (MSHA) J.D. NQ./Of'tlu! mine •ite --------

(e) SUUe Coal Sevemnce Tat Vmdor No. --------

(/) Ton.r uf wal produced (uaach legible copy a[ cotll •evei'IZrlce t<n: return for each l?•onrh during 

num recent 12 mOIII!u) • Pm ra/Jl shan:------

3. State the total projected prod~;c;tion for each year of the propo~ed 

permit for which assistance Is being sought. 

Other Operation(s) 

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• 

SMALL OPERATOR ASSISTANCE APPUCATION P8fO..Loi....L 

F. UNDERTAKING OF APPUCANT 

The undersigned, as a duly authorized representative of the applicant, hereby 

agrees that the applicant Intends to apply for a permit pursuant to the 

regulations and shall, if the applicant receives small operator assistance: 

1. Fu11y cooperate with all laboratories, their employees and agents, that 

wf11 produce the determination and statement; 

2. When requested, submit coal production information for the area affected 

by this application and for any other mining operation in which the 

appliCant has an interest or an operation which has an interest in the 

applicant; said information Is to be furnished within thirty (30) days 

of the end of the first twelve (12) months of mining activity and 

thereafter for each twelve (12) month period of mining under the permit 

for which assistance is provided; and, 

3. Notify the Office of Surface Mining Reclamation and Enforcement in 

writing within 10 days of any change (a) in ownership or mining plans 

that may affect assistance eligibility or permit eligibility pursuant to 

the information fn this application, or (b) that may require a change in 

the scope of work being performed by the contractor. 

4. Refund within 30 days to the Office of Surface Mining the full amount 

for labor;l.tory services paid pursuant to this applicant (with computed 

interest penalty) in accordance with Jg5.12(a}, upon presentation of 

appropriate receipts, if any of the fo7Jowing conditions occur: 

(a) lnfomuzlion submitted as required l>y paragraph (2) aboW! or from the aband<Jned. mme lands 

fee compliance :ry.<tem slwws actual and attritlls/ed coal prod.l<Ct:Wn to be jn excess of 100,()(}() 

tons d.uring any coru-ecutive 12·month period oither during the term of the permit for which 

assistance is prr:wided or dun"ng the [nt 5 .J"'BI'S after i<S~U~t~U of the permit, whkhever is 

slwrter, 

(b) knowingly submits false inf<Jm1alion; 

(c) Fails to submit a permit applkation within ooe (1) year from the date cifreceipt of the 

approved laboratory teporl; 

(d) Fails 10 commence mining after obtaining a permit; 

(e) Sells, /rQns[ers or as<igm the permit to another pers011 or company and the rransjeree's total 

a<:I!J.al and awibuled producnm~ exceeds the 100,(}(}(} 1011 annual production limit during any 

coru-eculive 12-month period of the rem<lining term af the permit. In this case. the applicant 

and its successor shall be jamtly and severally obligated for reimbursement. 
SMAL.l OPERATOR ASSISTANCE APPUCATION 

Undertak!na o1 the Agpllcant (continuation sheet} 

5. The operator, represented by the authorized cfl/llpany Qfffcfa1 (signature 

below), agrees to assume responsibility for the care, maintenance, and 

eventual disposal of any ground-water 11bservatfon we11s dri11ed on their 

beha1f. Upon completion of the Small Operator Assistance Program study, the use of and responsibility for these wells shalT transfer to the 

operator. FurthenfiOre, it sha11 be the responsfbf1ity of the operator 

to meet a11 appropriate state and Federal regulations regarding the 

continued use and/or eventual abandonment of these wells. 

G. AFFIDAVIT 

I, , as the applicant, or as a duly authorized 

representative, being ffrst duly sworn, state that to the best flf my knowledge 

all informatfon furnished in this applf(;ant fs true and col!lp-1ete. 

TITLE 

State of -----------

County of -----------

Subscribed and sworn to before me this __ day of ___ ,, 19_. 

My commfssfon expires ---------

(Notary Public) 

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