Permit No.________________ Page 1 of 2 Power of Attorney & Agreement (Partnership)

United States Department of the Interior

OFFICE OF SURFACE MINING RECLAMATION AND ENFORCEMENT

POWER OF ATTORNEY AND AGREEMENT FOR COLLATERAL BOND

(Partnership)

KNOW ALL PERSONS BY THESE PRESENTS, that I, the undersigned, of carrying on 

business in the partnership together under the firm name and style of 

__________________________________________________________________________, 

(Name of Partnership/Permittee)

_________________________________________________________________________________________,

(Street Address, City, State, Zip)

do hereby constitute and appoint ________________________________________________ (Name and official title of Bond-Approving Officer)

and his/her successors in office, as attorney of me and each partner, and of our said firm of 

____________________________________ in the name or names and on behalf of us and our 

 (Name of Partnership/Permittee)

said firm, 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 us, as security for the faithful performance 

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

United States, under date of _______________________, with respect to Permit No. _________, (Date Collateral Bond Signed)

which is hereby made a part hereof, and we agree that, in case of any default in the performance 

of any of the conditions and stipulations of such undertaking, our 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 we hereby for ourselves, our heirs, executors, administrators, and assigns, ratify and 

confirm whatever our said attorney shall do by virtue of those present.
Permit No.________________ Page 2 of 2 Power of Attorney & Agreement (Partnership)

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

of ______________________, ______. 

By: _____________________________________ 

(Partnership/Permittee)

By:__________________________________________ 

(Partner) 

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 a partner of __________________________, the partnership named 

in the foregoing instrument, and that he/she, being authorized so to do, executed the foregoing 

instrument on behalf of said partnership. 

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 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