Permit No._____________ Page 1 of 2 Power of Attorney & Agreement (Corp)

United States Department of the Interior

OFFICE OF SURFACE MINING RECLAMATION AND ENFORCEMENT

POWER OF ATTORNEY AND AGREEMENT FOR COLLATERAL BOND

(Corporation)

KNOW ALL PERSONS BY THESE PRESENTS, that 

__________________________________________________________________________, (Name of Corporation – Permittee)

a corporation duly incorporated under the laws of the State of ________________________, in 

pursuance of a resolution of the Board of Directors of said corporation, passed on the _______ 

day of ___________________, ________, does hereby constitute and appoint 

________________________________________________ and his/her successors in office, 

(Name and official title of Bond-Approving Officer)

and his/her successors in office, as attorney for said corporation to collect or to sell, assign and 

transfer certain securities, certificates of deposit or other instruments described as follows:

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

such negotiable securities having been deposited by it, as security for the faithful performance of 

any and all of the conditions or stipulations of a certain obligation entered into by it with the 

United States, under date of _______________________, with respect to Permit No. _________,

(Date Collateral Bond Signed)

which is hereby made a part hereof, and the undersigned agrees that, in case of any default in the 

performance of any of the conditions and stipulations of such undertaking, its said attorney shall 

have full power to collect said securities or any part thereof, or to sell, assign, and transfer said 

securities or any part thereof without notice, at public or private sale, free from any equity of 

redemption and without appraisement or valuation, notice and right to redeem being waived, and 

to apply the proceeds of such sale or collection, in whole or in part, to the satisfaction of any 

damages, demands, or deficiency arising by reason of such default, as its said attorney may deem 

best; and the undersigned further agrees that the authority herein granted is irrevocable.

And said corporation for itself, its successors and assigns, ratifies and confirms whatever its said 

attorney shall do by virtue of these presents.
Permit No._____________ Page 2 of 2 Power of Attorney & Agreement (Corp)

IN WITNESS WHEREOF, the Obligor has hereunto set its signature this _________ day of 

____________, ______. 

_____________________________________ 

(Corporation – Permittee)

By:__________________________________________ 

(Corporate Officer) 

Title:_____________________________________ 

ACKNOWLEDGEMENT

On this ______ day of ____________________,________, before me, a Notary Public in 

and for the County of _______________________, in the State of ________________________, 

appeared _______________________________ to me personally known who, being by me duly 

sworn, did say that he/she is _________________________ of __________________________, 

the corporation named in and which executed the within instrument, and that the seal affixed to 

said instrument is the corporation seal of said corporation, and that said instrument was signed, 

sealed, and delivered in behalf of said corporation by authority of the Board of Directors, and 

he/she, as such officer, acknowledged said instrument to be the free act and deed of said 

corporation for the uses and purposes of said instrument as therein set forth. 

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

month, and year aforesaid. 

My Commission Expires: ________________________________________________ 

(Notary Public in aforesaid County and State)

NOTE: Securities must be described by issuing institution, title, date of maturity, rate of interest, 

denomination, serial number, and whether coupon or registered.

Paperwork Reduction Act Notice

We use the information required by this form to ensure that the requirements for a collateral bond under 30 CFR 

800.21 have been met. You must provide the requested information to obtain a benefit (a collateral bond). Under 

30 CFR 842.16, the information collected is a matter of public record.

The time needed to complete this form and related forms and submit the requested information to obtain a collateral 

bond 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 forms. If you have comments concerning the accuracy 

of this estimate or suggestions for simplifying the forms 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