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

Part 1 -- OSM-1

Coal Reclamation Fee Report

Title 30 U.S.C. Section 1232 provides that any person, corporate officer, agent or director, on behalf of a coal mine operator who knowingly makes any false statements, r

knowingly fails to make any statement, representation or certification required in this section shall, upon conviction, be punished by a fine of not more than $10,000, or by ione year or both. Approved by OMB, no.1029-0063. Expires 2/28/2027 Call 1-800-799-4265 if you have any questions

Reporting for 

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 ,nd2 ܆

܆ 3rd, or 

܆ 4th quarter, 20____.

This certification covers the following permit number(s):

State Permit Number

I hereby certify that the statements made correct to the best of my knowledge and faith________________________________________Print in ink or type the name of reporting person, con behalf of the operator or the permittee signing b________________________________________

Signature 

Contact name:Telephone:Email:Entity:

- Submit a properly notarized copy of the OSM-1 formSubscribed and sworn to before me in my presence the ______ day 

of __________, 20______.

______________________________________Notary Public signature Commission expires:_______

Amount D

Credits or Amo

due from previous f

Total D

Total Paym

Check one:

- Sign an unsworn s

“I declare under penalty of perjury th

correct. Executed on _____ day 

_____________________________

Signature

OR

5.

4.

3.

2.

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Part 2 -- OSM-1 Coal Reclamation Fee Report, OSM-1

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Part 3 -- OSM-1 Coal Reclamation Fee Report, OSM-1

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 Permit Number Mine Name 

Coal Delivered to Address City State 

Purchasers of Coal Address City State 

Mineral Owners Address City State 

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If you pay by Check:

2IILFHRI6XUIDFH0LQLQJ5HFODPDWLRQ	(QIRUFHPHQW32%2;25065Lakewood, CO 80225

AML Fees Payment Deposit Coupon260'RFXPHQW1XPEHU(QWLW\1XPEHU(QWLW\1DPH<HDU4XDUWHU

(QWHU$PRXQWRI3D\PHQWV

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PLEASE INCLUDE THIS COUPON WITH YOUR CHECK TO ENSURE ACCURATE POSTING OF YOUR 

...

If you previously made payments to the lockbox for one or more mines less than $500, you may either elect to make payments via electronic fund transfer, as listed above, or you should update the payment mailing address to:

Paperwork Reduction Act StatementThis information is being collected to comply with the regulatory requirements of30 CFR 870.15(b) which requires each operator to use mine report OSM-1 form (and Amenreport the coal tonnage sold, used or ownership transferred during the applicable calendar quarter. Response to this request is mandatory in accordance with Section 402(and Reclamation Act of 1977, 30 USC 1232. Burden EstimatePublic reporting burden for the OSM-1 form based on one permit is 4 minutes to complete the electronic form and 7 minutes to complete the paper form. The burden estim

reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the form. Approved by OMB, no.1029-0