Permit No. _________________ Page 1 of 2 Collateral Amendment - Partnership

United States Department of the Interior

OFFICE OF SURFACE MINING RECLAMATION AND ENFORCEMENT

AMENDMENT TO COLLATERAL BOND AND INDEMNITY AGREEMENT

(Partnership)

To be attached to and form a part of the Collateral Bond and Indemnity Agreement 

executed by ______________________________________________________ AS OBLIGOR, 

(Partnership/Permittee)

in the sum of __________________________________________________________________

______________________________________ DOLLARS ($__________________________),

in favor of the United States Department of the Interior, Office of Surface Mining Reclamation 

and Enforcement (OSM) and executed on _______________________________.

Whereas, OSM issued Permit No._____________ and dated _______________, and Permit 

Renewals and Revisions numbered and dated: _______________________________

______________________________________________________________________________

pursuant to the application of the Obligor;

WHEREAS, said collateral bond and indemnity agreement and amendment shall cover 

any and all land affected or to be affected by the mining operation under the above-mentioned 

permit and revisions and renewals since the date of the issuance of the permit.

NOW, THEREFORE, the purpose of this amendment is:

It is further agreed that all other terms and conditions of this collateral bond and 

indemnity agreement shall remain unchanged.

IN WITNESS WHEREOF, the Obligor has hereunto set his/her signature and seal this

 day of ___________________, .

______________________________________________________

(affix seal) (Partnership – Permittee)

BY: ________________________________ 

 (Partner)

BY: ________________________________

(Partner)
Permit No. _________________ Page 2 of 2 Collateral Amendment – Partnership

ACKNOWLEDGEMENT OF PARTNERSHIP - OBLIGOR

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 partnership named in and which executed the 

within instrument, and that said instrument was signed, sealed and delivered on behalf of said 

partnership 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: Where negotiable securities are used as collateral, a complete POWER OF ATTORNEY 

AND AGREEMENT must be attached.

Paperwork Reduction Act Notice

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

800.21 are met. You must provide the requested information to obtain and retain 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 submit the requested information will vary depending on individual 

circumstances. We estimate that the average time will be 2 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, Room 202 SIB, 1951 Constitution Ave, NW, Washington, D.C. 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 11/30/2018