Permit No. L/C No. ____________________

United States Department of the Interior

OFFICE OF SURFACE MINING RECLAMATION AND ENFORCEMENT

(Bank Letterhead)

IRREVOCABLE LETTER OF CREDIT

Beneficiary: Issuing Bank: ________________________

(Name)

United States Office of Surface Mining ________________________

Reclamation and Enforcement (OSM) (Address)

1999 Broadway, Suite 3320 ________________________

Denver, Colorado 80202-5733 (City, State, Zip)

________________________

Permit Number: (Telephone)

Letter of Credit Number: Amount: $__________________

Date of Issue: Date of Expiry: _________________

Ladies/Gentlemen:

On behalf of __________________________, _______________________________ (Permittee/Applicant for L/C) (Address)

we (Bank) hereby establish an Irrevocable Letter of Credit (LOC) payable in part or full to the 

United States Department of the Interior, Office of Surface Mining Reclamation and 

Enforcement (OSM), available by draft(s) in an amount not to exceed _______________

_________________________________ ($ ), upon receipt of a written 

demand by OSM pursuant to 30 CFR §800.50.

This Letter of Credit is effective (Date) , (Year) , and will expire at the 

close of business on (Date) , (Year) . However, this letter of credit will 

automatically be extended for periods of year(s) from any scheduled expiration date (as 

originally scheduled or automatically extended) unless ninety (90) days prior to such date we 

notify you in writing by certified mail, return receipt requested, that we elect not to renew this 

Letter of Credit for such additional period. 

Upon receipt of such notice, you may draw on us at sight for the amount of this Letter of 

Credit beginning thirty (30) days or less prior to the then-applicable expiration date, 

accompanied by a statement signed by the OSM Bond-Approving Officer or his/her designee 

certifying that the amount of the drawing represents funds due OSM because the permittee has 

failed to replace this Letter of Credit by other suitable bond or letter of credit pursuant to 30 CFR 

§800.21(b)(2) and 30 CFR §800.30.

We certify that the amount of the credit herein established will not be reduced for any 

reason during the period of this instrument without the written consent of OSM.
Permit No. L/C No. ____________________ 

Pursuant to 30 CFR §800.16(e)(1), we will give prompt notice to the permittee and to the 

OSM Bond-Approving Officer of any notice received or action filed alleging the insolvency or 

bankruptcy of the Bank, or alleging any violations of regulatory requirements which could result 

in suspension or revocation of the Bank’s charter or license to do business. 

In the event the Bank becomes unable to fulfill our obligations under this Letter of Credit 

for any reason, we shall give immediate notice to the permittee and to the OSM Bond-Approving 

Officer.

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

day of , . 

__________________________________________________(Issuing Bank)

(Authorized Officer’s Printed Name and Title)

(Authorized Officer’s Signature)

ACKNOWLEDGEMENT

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 Bank named in and 

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

said Bank, and that said instrument was signed, sealed and delivered on behalf of said Bank 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 Bank for the uses and purpose 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 and for said County and State

Paperwork Reduction Act Notice

We use the information required by this form to ensure that the requirements for posting a letter of credit as 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 an irrevocable letter of credit). 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 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 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