Permit No._____________ Page 1 of 3 Mortgage or Trust Deed

United States Department of the Interior

OFFICE OF SURFACE MINING RECLAMATION AND ENFORCEMENT

MORTGAGE OR DEED OF TRUST

THIS INDENTURE, made and entered on this ______ day of ____________________, ______, 

between ________________________________________________ herein referred to as the 

Grantor, the Office of Surface Mining Reclamation and Enforcement (OSM), United States 

Department of Interior, herein referred to as the Trustee, and the United States of America, 

herein referred to as the Beneficiary.

WITNESSETH: A first mortgage, first deed of trust or first-lien security granting OSM a 

security interest in the Real Property described below, with a right to sell or otherwise dispose of 

the property in the event of a forfeiture under 30 CFR §800.50, is hereby given to OSM as 

collateral by the Grantor. The OSM security interest in the property shall be in the amount of $

________________________ and shall be for the purpose of securing the cost of the Grantor’s 

reclamation obligations under Permit No. ____________.

(Description of Real Property covered by deed of trust.)

The above described real property, consisting of _________ acres in the aggregate, more or less, 

was conveyed to the Grantor, __________, by warranty deed from ___________ as evidenced 

by being recorded in Book _______________, Page _______ of _________________, in the 

records of ____________County Clerk’s Office.

To have and to hold said real estate to the Trustee in trust for the purposes hereinafter set forth.

The Grantor covenants with the Trustee that it is lawfully seized in fee simple of the real estate 

above conveyed, has full power, right and authority to convey same, that said real estate is free 

from all encumbrances, and that it will forever warrant and defend it and the legal title thereto 

against the lawful claims of all persons whomsoever.

The Grantor shall not sell or encumber any portion or interest of the real estate covered by the 

deed of trust.

The Grantor agrees to pay all taxes assessed on the real estate as they become due and owing and 

to adduce proof of the payment of same by providing Trustee with a copy of the paid receipt 

within thirty (30) days of paying of same.

The Grantor agrees not to commit waste of any sort.
Permit No._____________ Page 2 of 3 Mortgage or Trust Deed

This mortgage or deed of trust will be recorded in the appropriate office in the county in which 

the real property is located and will operate as a lien on that property in favor of the Trustee.

In the event the Grantor fails to comply with any of the foregoing conditions, then the Trustee 

shall be entitled to foreclose upon the real estate.

The conveyance is made in trust to the Trustee for the following uses and purposes and none 

other.

As a bond to secure reclamation under the Laws and Regulations of the United States 

Department of the Interior, Office of Surface Mining Reclamation and Enforcement under 

Application No.__________, Permit No.____________, in the amount of $________________.

In the event the bond secured hereby is forfeited, or in the event any of the covenants, 

undertakings or premise conditions set out herein be breached or not performed, then the Trustee 

shall, after giving notice of the time and place of sale by certified mail to Grantor, or by weekly 

publication in a newspaper published in ______________ County, __________________, at 

least twenty (20) days previous to said sale, and on the day and at the time and place designated 

in the notice, sell the property above conveyed at public auction to the highest bidder for cash in 

hand in bar of the right and equity of redemption, which is hereby waived and surrendered, and 

all other rights which Grantor might have in said property. The Trustee shall apply the proceeds 

from the sale as follows:

1. to the payment of all costs and expenses of the sale, including a fee of 10 percent to the 

trustee, which fee shall become absolutely due and payable whenever foreclosure is 

commenced;

2. to the reclamation of Permit No. ___________ hereby secured and any taxes unpaid or 

that are a lien on the property at the date of the sale; and

3. the surplus, if any, to the Grantor.

The Grantor further agrees that in case of sale of the above-described property that it will at once 

become and be a tenant at will of the purchaser, and will surrender the possession thereof on 

demand. If such possessions be not given, then Grantor may be removed by a forcible and 

unlawful detainer action and the Grantor agrees to pay the purchaser the reasonable rental value 

of the property from the date of sale for as long as they shall be in possession thereof.

Any of the parties hereto my bid and become a purchaser at any sale hereunder.

The failure of the Trustee to have this deed of trust foreclosed immediately upon any default 

provided herein shall not be construed so as to preclude foreclosure at a later date for such 

default if same still exists at the time and shall not be construed so as to prevent foreclosure for 

similar subsequent default.
Permit No._____________ Page 3 of 3 Mortgage or Trust Deed 

IN WITNESS WHEREOF, the Grantor has hereunto set its hand at the place and on the date first 

above-written.

State of __________________________ 

County of ________________________ 

On this _______ day of ___________________________, A.D. ________ before me 

personally appeared _______________________________, to me known to be the 

_____________________________ [President, Vice President, Secretary, Treasurer, or other 

authorized officer or agent, partner or owner as the case may be] of the corporation, partnership 

or sole proprietorship that executed the within and foregoing instrument, and acknowledged the 

said instrument to be a free and voluntary act and deed of said entity, for the uses and purposes 

therein mentioned, and on oath stated that he/she was authorized to execute said instrument and 

that, if the entity is a corporation, the seal affixed is the corporate seal of said corporation. 

IN WITNESS WHEREOF, I have hereunto set my hand and affixed my official seal the 

day and year first above written: __________________________________________ 

Notary Public in and for the State residing at __________________________________________. 

Paperwork Reduction Act Notice

We use the information required by this form to ensure that the requirements for posting an interest in real property 

as a collateral bond under 30 CFR 800.21 are met. You must provide the requested information to obtain a benefit 

(a collateral bond that relies upon real property). 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 10.5 hours 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, 1849 C Street, NW, Room 4559, Washington, DC 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 10/31/2021