Permit No._______________ Page 1 of 2 Power of Attorney & Agreement (Sole Prop)

United States Department of the Interior

OFFICE OF SURFACE MINING RECLAMATION AND ENFORCEMENT

POWER OF ATTORNEY AND AGREEMENT FOR COLLATERAL BOND

(Sole Proprietorship)

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

__________________________________________________________________________, 

(Name of Company – 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 for me and in my name 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 me, as security for the faithful performance 

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

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

(Date Collateral Bond Signed)

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

any of the conditions and stipulations of such undertaking, my 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 my said attorney may deem best; 

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

And I hereby for myself, my heirs, executors, administrators and assigns, ratify and confirm 

whatever my said attorney shall do by virtue of these presents. 

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

of ____________, ______. 

_____________________________________ (Company – Permittee)

By:__________________________________________ 

(Proprietor) 
Permit No._______________ Page 2 of 2 Power of Attorney & Agreement (Sole Prop)

ACKNOWLEDGEMENT

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 on the forgoing instrument and who, being by me duly sworn, did say that 

he/she executed the same for the purposes therein 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)

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 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 4554, 

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