Permit No. Page 1 of 3 Certificate of Deposit – Individual

United States Department of the Interior

OFFICE OF SURFACE MINING RECLAMATION AND ENFORCEMENT

ASSIGNMENT OF CERTIFICATE OF DEPOSIT FOR COLLATERAL BOND

(Sole Proprietorship)

Whereas, on the day of , 

(Name of Company – Permittee)

(Street Address, City, State, Zip Code)

executed (a) certain Certificate(s) of Deposit described as follows:

to secure performance of certain reclamation under Surface Coal Mining Permit No.

.

WHEREAS, under 30 CFR 800.21(a)(3) the permittee is required to post an acceptable 

new certificate or provide an executed assignment of the existing certificate made payable to the 

regulatory authority. 

NOW THEREFORE, to satisfy the requirements of 30 CFR § 800.21(a)(3), the

undersigned 

(Name of Company – Permittee)

as Obligor, hereby assigns its

interest in the Certificate(s) of Deposit as described above, made payable to the “United States

Department of the Interior, Office of Surface Mining Reclamation and Enforcement.” 

THE CONDITION OF THE ABOVE ASSIGNMENT is such that the certificate shall: 

(a) be assigned to the United States Department of the Interior, Office of Surface

Mining Reclamation and Enforcement, both in writing and upon the books of the 

institution issuing such certificates;

(b) individually not exceed $100,000 or the maximum insurable amount as 

determined by F.D.I.C and F.S.L.I.C.; 

(c) be conditioned upon the Issuing Institution waiving all rights of set-off or liens 

which it has or may have against such certificates;

(d) be deposited in sufficient amounts, so that liquidation of those certificates prior to
Permit No. Page 2 of 3 Certificate of Deposit – Individual

maturity would provide the required bond amount;

(e) the assignment shall remain in full force and effect until released in writing by the

Office of Surface Mining Reclamation and Enforcement.

This assignment shall be valid throughout any maturity redemption period as designated 

by the Issuing Institution, and shall also automatically renew itself when the Certificate(s) of 

Deposit is renewed.

IN WITNESS WHEREOF, the Obligor has hereunto set its signature and seal this

day of , .

(Company-Permittee)

By:_

(Individual – Sole Proprietor)

IN WITNESS WHEREOF, he Issuing Institution has hereunto set its signature and seal 

this day of , .

(Issuing Institution)

By:_

Title:

ACKNOWLEDGEMENT OF INDIVIDUAL – PERMITTEE

On this day of _ , , before me, a Notary Public in

and for the County of , in the State of ,

appeared personally known to me to be the person whose name

is subscribed to the foregoing instrument and who, being by me fully sworn, did say that he/she 

executed the same for the purposes herein contained.

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)
Permit No. Page 3 of 3 Certificate of Deposit – Individual

ACKNOWLEDGEMENT OF ISSUING INSTITUTION

On this day of , , before me, a

Notary Public in and for the County of 

, appeared 

known who, being by me duly sworn, did say that he/she is

, in the State of 

, to me personally 

,

of , the Issuing Institution named in and which

executed the within instrument, and that the seal affixed to said instrument is the corporation seal 

of said Issuing Institution, and that said instrument was signed, sealed and delivered in behalf of 

said corporation by authority of its 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)

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 that relies 

upon certificates of deposit). 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