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

Part 1 OSM-1
Coal Reclamation Fee Report

1. Reporting for 1st 2nd 3rd 4th quarter,
This cetification covers the following permit number(s):

I hereby certify that the statements made herein are true, complete and
correct to the best of my knowledge and belief and are made in good faith:

Print in ink or type the name of the reporting person, corporate officer,
agent or director on behalf of the operator or the permitee.
signature: date:

Subscribed and sworn to before me in my presence the
day of , .

Notary Public signature

My commision expires

Contact person:
telephone number ()
Master entity number:
Reporting entity number
Check one electronic funds transfer

5. Total Payment enclosed
$ .

To submit the report, press:

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 false statements, representation or
certification, or 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 imprisonment for not more than one year or both.
Approved by OMB, no. 1029-0063. Expires 7/97
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