Free 02192.pdf - Indiana

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State form 2192 (R2/10-03) / Form R-100 Approved by State Board Of Accounts 2004

DIVISION OF RECLAMATION INDIANA DEPARTMENT OF NATURAL RESOURCES INDIANA CODE 14-36-1 APPLICATION FOR A PERMIT I. GENERAL INFORMATION (Please Type or Print ALL Information)

A. B.

Name of Operator: Permanent Address:

. D. Temporary Field Address: . . .

C.

Telephone #:

E.

Telephone #:

.

This application must be accompanied by the following information, if issued by the Secretary of State's Office, Room 155, State Capitol Building, Indianapolis, Indiana, by operator doing business within the State of Indiana. Check Attachment(s) submitted: Corporations (Within the State of Indiana) Good Standing Certificate Certified Copy of Articles of Incorporation Corporations (Outside the State of Indiana) Good Standing Certificate Certified Copy of the Application of Admission

If the above is not applicable, check and complete below: Federal Identification #: II. PROPOSED MINING AREA A. C. D. Pit Name or Number: Acres proposed to be mined under this permit: Legal Description (Include quarter-quarter section, quarter section(s), Section(s), Township(s) and Range(s), USGS Quadrangle Map): B. County(s): .

Form R-100

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E.

Distance and direction from permanent feature such as a town, highway, junction, church, etc.:

F.

List below the name and address of the owner(s) of the mineral to be mined (attach additional sheets if necessary):

G.

List below the name and address of the owner(s) of the surface to be affected (attach additional sheets if necessary):

III. FEES A. Required fees submitted with this application are as follows: $ $ $ (1) Permit Fee ($100 each application) (2) Acreage Fee ($50 each acre and every fraction of an acre) (3) Total Fees Submitted IV. BOND A. B. (1) Based on applicable factors from Form R-102 "Bond Evaluation Factor Sheet" the total bond submitted for . the acreage in this application is $ Type of Bond (Complete only applicable item): Surety: Bond #: Name of Surety Company: (2) Certificate of Deposit: Certificate #: Name of Bank:

Address of Surety Company:

Address of Bank:

(3)

Cash: $

Form R-100

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Access to the area under application is hereby granted for the Director or his delegate as authorized by Section 5(b)(IV) Indiana Code 14-36-1. THIS APPLICATION MUST BE ACCOMPANIED BY THE DOCUMENTS DESCRIBED IN TABLE OF CONTENTS, ITEM IV, or the application is considered incomplete and shall be returned to the operator. Signed at: this day of Name of Operator: Responsible Official: Title: Subscribed and sworn to before me this My commission expires day of , 20 . , 20 , .

Notary Public

One (1) notarized copy

REVISED JULY 2001

I:\Barb forms\State Approved Forms\R-100_Clay_Shale_Permit_Application.doc