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

United States Department of the Interior

OFFICE OF SURFACE MINING RECLAMATION AND ENFORCEMENT

AMENDMENT TO COLLATERAL BOND AND INDEMNITY AGREEMENT

(Corporation) 

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

executed by ______________________________________________________ AS OBLIGOR, 

(Corporation – 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 on _______________, 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 its signature and seal this 

 day of ___________________, . 

________________________________ By: ________________________________ 

 (Corporation/Permittee) (Corporate Officer1) 

_____________________________

(Title) 

1

Where one signs by virtue of Power of Attorney or Corporate Resolution for a corporate Principal, a certified copy of the Power 

of Attorney or Corporate Resolution must be filed with the collateral bond.
Permit No. _________________ Page 2 of 2 Collateral Amendment - Corporate 

ACKNOWLEDGEMENT OF CORPORATION - 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 fully 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 corporate 

seal of said corporation, and that said instrument was signed, sealed and delivered on 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 

NOTE: Where negotiable securities are used as collateral, a completed 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 a collateral bond under 30 CFR 

800.21 are met. You must provide the requested information to obtain or 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, 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