Work declaration form
Within the meaning of the Act respecting access to documents held by public bodies and the protection of personal information,
the information identifying you is confidential. However, this information is essential for the processing of your file. Thus, the
Department commits itself to restrict access to duly authorized people and to use and dispose of the confidential information in
compliance with this Act.
IDENTIFICATION
AND WORK SYNTHESIS
SECTION 1 : APPLICANT (Obligatory)
Please inscribe the contact information of the person completing this form. The correspondence pertaining to the work report shall be sent and
used for any additional information request.
Name
First name
Client number
Address
Province
City
Country
Postal code
Fax
Phone
Ext.
E-mail address
SECTION 2 : OPERATORS (Obligatory)
Please identify the operators as specified in the article 1 of the Mining tax act, c. I-0.4 and their percentage partnership for all the titles and work
declared.
1.
Name
Client number
Address
Province
City
Country
Postal code
Fax
Phone
Ext.
E-mail address
Quebec enterprise number (NEQ)
Percentage partnership
2.
Name
Client number
Address
Province
City
Country
Postal code
Fax
Phone
Ext.
E-mail address
Quebec enterprise number (NEQ)
Percentage partnership
SECTION 3 : PROPERTIES / PROJECTS (Obligatory)
Please name the properties / projects associated with this declaration.
Name
Ministère de l’Énergie et des Ressources naturelles
Service de la gestion des droits miniers
2015-11-18 – Page 1 de 3
SECTION 4 : STATEMENT (Obligatory)
As a mining right holder or his representative, you are responsible for all the information disclosed in this form. Select the appropriate box,
write your name in block letters, the date and sign the statement.
Statement of the mining right holder
or his representative
I hereby certify that all information provided in this form, its annexes and attached documents is accurate, complete and submitted once only. I
acknowledge to be the holder of this or these mineral rights or his duly authorized representative.
Name
First name
Date :
/
Year
Signature :
/
month
Day
Do not forget to attach the maps, plans, reports and registers required by regulation.
This form must be sent by mail only at the following address :
Ministère des Ressources naturelles
Service de la gestion des droits miniers
5700, 4e Avenue Ouest, local C-320
Québec (Québec) G1H 6R1
RESERVED TO THE MINISTÈRE
No de requête :
Ministère de l’Énergie et des Ressources naturelles
Date de réception :
Service de la gestion des droits miniers
Initiales :
2015-11-18 – Page 2 de 3
SECTION 3 : WORK SYNTHESIS
First, write the location of titles on the upper line and select the appropriate boxes. Then for each titles aimed in this statement, report here all the amounts declared in each annexes concerned and according to the nature of work performed. To do so, enter in the first
column the title n° number, in the second column the number of corresponding hectares and, in the following columns, the amount reported according to the nature of work performed. Moreover, write at the end of each column and each line the total of costs as well as
the great total.
Location :
Township
Seigniory
GP
Mining title n°
Nbre of
Hectares
N.T.S.leaflet
GE
GC
Geophysical surveys Geological surveys Geochimical surveys
FO
EP
DE
AN
EV
AU
Boring (drilling)
Property examination
Stripping/Excavating
Sampling
Technical
assessement
Other
TOTAL
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
TOTAL AMOUNT
GREAT TOTAL
Note : If the space is insufficient, print another page
Ministère de l’Énergie et des Ressources naturelles
Service de la gestion des droits miniers
2015-11-18 – Page 3 de 3
ANNEXE
1
Geophysical, geological and geochemical surveys
SECTION 1 : LINE CUTTING
Describe briefly the type of lines (indicated, cut, staked, etc). Write the period (year, month, day) during which cutting was carried out, the number of
kilometers covered and the spacing between the lines. Enter in the last column the corresponding cost. Then add all the expenses and enter the total
amount in box entitled TOTAL (1). Where applicable, distribute this amount between the various surveys in the space reserved for this purpose in sections 2,
3 and 4.
Nature of cutting
Date(s) of performance
from (year/month/day) to (year/month/day)
Length
in (km)
Spacing between lines
Cost
$
+
+
+
+
+
+
+
+
+
+
=
TOTAL (1)
SECTION 2 : GEOPHYSICAL SURVEYS
Describe the method used, the period (year, month, day) during which surveys were carried out, the number of kilometers covered, the spacing between
reading points, the number of readings and finally, in the column entitled COST, expenses incurred for each surveys. Where applicable, enter the attributable
amount to line cutting. Add the entered amounts and inscribe in box entitled TOTAL (2) the total sum of costs disbursed.
This total must be deferred to section entitled "Identification and work synthesis" and distributed, by title, according to the nature of work.
Method used
Length
in (km)
Date(s) of performance
from (year/month/day) to (year/month/day)
Spacing between reading
points
(in meters)
Interval
Number
Cost
$
+
+
+
+
+
+
+
+
+
+
Montant attribuable pour la coupe de lignes
=
TOTAL (2)
SECTION 3 : GEOLOGICAL SURVEYS
Describe the method used , the period (year, month, day) during which surveys were carried out, the number of kilometers covered, the interval between
traversings and finaly, in the column entitled COST, enter the expenses incurred for each surveys. Where applicable, enter the ascribable amount to line
cutting. Add the entered amounts and inscribe in box entitled TOTAL (3) the total sum of costs disbursed
This total must be deferred to section 3 in the zone entitled "Identification and work synthesis" and distributed, by title, according to the nature of
work.
Method used
Date(s) of performance
from (year/month/day) to (year/month/day)
Surface
(in km2)
Interval between the
traversings
(in metrers)
+
+
+
+
+
+
+
+
+
+
Montant attribuable pour la coupe de lignes
TOTAL (3)
Ministère de l’Énergie et des Ressources naturelles
Cost
$
Service de la gestion des droits miniers
=
Annexe 1 – 2015-11-18 – Page 1 de 2
SECTION 4 : GEOCHEMICAL SURVEYS
Describe the method used , the period (year, month, day) during which surveys were carried out, the number of kilometers covered , the interval between
sampling points, the number of samples and finaly, in the column entitled COST, enter the expenses incurred for each surveys. Where applicable, enter the
attributable amount to line cutting. Add the entered amounts and inscribe in box entitled TOTAL (4) the total sum of costs disbursed.
This total must be deferred to section 3 in the zone entitled "Identification and work synthesis" and distributed, by title, according to the nature of
work.
.
Method used
Date(s) of performance
from (year/month/day) to (year/month/day)
Length
(in km)
Interval between samples
(in metrers)
Interval
Cost
$
Number
+
+
+
+
+
+
+
+
+
+
Amount attributable to line cutting
TOTAL (4)
=
SECTION 5: EXPENSES INCURRED FOR LINE CUTTING AND SURVEYS
Detail here the various expenses incurred for line cutting and surveys by describing, for example, the costs incurred for wages, housing, supplying,
transportation, instruments rental, analyses, drawings, etc. Moreover, indicate for each ones the corresponding cost. Add all the entered amounts and
inscribe the total in box entitled Total (5).
Cost
$
Description
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
Caution, the total of this box must correspond to the total amount of previous TOTALS 2, 3 et 4.
Ministère de l’Énergie et des Ressources naturelles
Service de la gestion des droits miniers
TOTAL (5)
=
Annexe 1 – 2015-11-18 – Page 2 de 2
ANNEXE
2
BORING WORK (DRILLING)
SECTION 1 : LABOUR COSTS
List the name and address of the contractor in charge of carrying out the work program or the name and address of the personnel who participated in the work
as well as the period (year, month, day) during which the work has been carried out . In the last column, inscribe the amounts disbursed for wages to the
personnel or the cost disbursed to the contractor for the carrying out of work. Finally, add each costs and enter the total amount disbursed in box entitled
TOTAL (1)
Identification
Name
Date(s) of performance
Address
Wages or cost
from (year/month/jday) to (year/month/day)
$
+
+
+
+
+
+
+
=
TOTAL (1)
SECTION 2 : TRANSPORTATION AND HOUSING OF PERSONNEL AND SUPPLYING COSTS
Detail briefly the type of transportation, housing and supplying. Inscribe the costs incurred for each one such as expenses for truck or vehicle rental,
accomodation, restaurant or grocery shopping, etc.
Moreover, write for each means of transport the distance covered, in kilometers (km) from starting point to arrival point on the site, the number of people
transported as well as the number of days of travelling . Then add each costs and enter the total amount disbursed in the box entitled TOTAL (2).
Distance
Description
(in km)
Nbre of
people
Nbre of
days
Cost
$
+
+
+
+
+
+
+
=
TOTAL (2)
SECTION 3 : SAMPLES ANALYSES
Write the name of the laboratorie(s) who performed the samples analyses, the elements determined, the number of samples analyzed as well as the cost for
each analysis. Add all the costs reported and enter the total amount in the box entitled TOTAL (3).
Name of laboratory
Elements determined
Nbre of
samples
Cost
$
+
+
+
+
+
+
+
TOTAL (3)
=
SECTION 4 : OTHER COSTS
Use this section to declare any other type of expenses incurred for drilling. Briefly describe the nature of expenses and enter the corresponding cost. Add
each cost and enter the total amount in box entitled TOTAL (4)
Description
+
+
+
+
+
TOTAL (4)
Ministère de l’Énergie et des Ressources naturelles
Service de la gestion des droits miniers
Cost
$
=
Annexe 2 – 2015-11-18 – Page 1 de 2
GREAT TOTAL (TOTAL 1 + 2 + 3 + 4)
Enter the total amount of expenses for boring work (drilling). This great total must be deferred to section 3 entitled "Identification and work synthesis" and
distributed by title according to the nature of work.
GREAT TOTAL (1 + 2 + 3 + 4) =
SECTION 5: BORING WORK (DRILLING) DESCRIPTION PER MINING RIGHT
In the following columns, list the number of titles and drill-holes on the land subject to the mining right as well as the overall length of the drill-holes in meters.
Lastly, write the total number of meters of land drilled for all the titles in the box entitled OVERALL LENGTH OF DRILL-HOLES.
Mining title n°
Drill-holes n°on this title
Total lenght of drill-holes
on this title
(in meters)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
TOTAL LENGTH OF DRILL-HOLES (IN METERS)
Ministère de l’Énergie et des Ressources naturelles
Service de la gestion des droits miniers
Annexe 2 – 2015-11-18 – Page 2 de 2
ANNEXE
3
EXAMINATION OF ROCK OUTCROPS AND ERRATIC BOULDERS
SECTION 1 : LABOUR COSTS
List the name and address of the contractor in charge of carrying out the work program or the name and address of the personnel who participated in the work
as well as the period (year, month, day) during which the work has been carried out . In the last column, inscribe the amounts disbursed for wages to the
personnel or the cost disbursed to the contractor for the carrying out of work. Finally, add each costs and enter the total amount disbursed in box entitled
TOTAL (1)
Identification
Name
Date(s)of performance
Address
Wages or cost
from (year/month/jday) to (year/month/day)
$
+
+
+
+
+
+
+
+
=
TOTAL (1)
SECTION 2: TRANSPORTATION AND HOUSING OF PERSONNEL AND SUPPLYING COSTS
Detail briefly the type of transportation, housing and supplying. Inscribe the costs incurred for each one such as expenses for truck or vehicle rental,
accomodation, restaurant or grocery shopping, etc.
Moreover, write for each means of transport the distance covered, in kilometers (km) from starting point to arrival point on the site, the number of people
transported as well as the number of days of travelling . Then add each costs and enter the total amount disbursed in the box entitled TOTAL (2).
Distance
Description
(in km)
Nbre of
people
Nbre of
days
Cost
$
+
+
+
+
+
+
+
+
TOTAL (2)
=
SECTION 3 : OTHERS COSTS
Use this section to report any other type of expenses incurred in property examination. Briefly describe the nature of expenses and enter the corresponding
cost. Finally, add each cost and enter the total amount in the box entitled TOTAL (3)
Description
+
+
+
+
+
+
+
+
+
TOTAL (3)
Cost
$
=
GREAT TOTAL (TOTAL 1 + 2 + 3)
Enter the total amount of expenses incurred in property examination.
This great total must be deferred to section 3 entitled "Identification and work synthesis" and distributed, by title, according to the nature of work.
GREAT TOTAL (1 + 2 + 3) =
Ministère de l’Énergie et des Ressources naturelles
Service de la gestion des droits miniers
Annexe 3 – 2015-11-18 – Page 1 de 1
ANNEXE
4
STRIPPING AND EXCAVATING WORK
SECTION 1 : LABOUR COST
List the name and address of the contractor in charge of carrying out the work program or the name and address of the personnel who participated in the work
as well as the period (year, month, day) during which the work has been carried out . In the last column, inscribe the amounts disbursed for wages to the
personnel or the cost disbursed to the contractor for the carrying out of work. Finally, add each costs and enter the total amount disbursed in box entitled
TOTAL (1)
Identification
Name
Date(s)of performance
Address
Wages or cost
from (year/month/jday) to (year/month/day)
$
+
+
+
+
+
+
=
TOTAL (1)
SECTION 2: TRANSPORTATION AND HOUSING OF PERSONNEL AND SUPPLYING COSTS
Detail briefly the type of transportation, housing and supplying. Inscribe the costs incurred for each one such as expenses for truck or vehicle rental,
accomodation, restaurant or grocery shopping, etc.
Moreover, write for each means of transport the distance covered, in kilometers (km) from starting point to arrival point on the site, the number of people
transported as well as the number of days of travelling . Then add each costs and enter the total amount disbursed in the box entitled TOTAL (2)..
Distance
Description
(in km)
Nber of
people
Nber of
days
Cost
$
+
+
+
+
+
+
=
TOTAL (2)
SECTION 3: FREIGHT CHARGES AND TYPE OF MACHINERY USED AS WELL AS THE COST OF MACHINERY AND EQUIPMENT USED
FRAIS DE TRANSPORT ET D’UTILISATION DE LA MACHINERIE ET DU MATÉRIEL ET TYPE DE MACHINERIE UTILISÉE
Describe briefly the means of transport used to move the machinery and equipment on the site as well as the type (brand, model, etc.) of machinery used.
Moreover, indicate, for each means of transport used, the distance covered, in kilometers (km) from starting point to arrival point on the site, the cost as well
as the duration of utilization of this equipment in hours and the corresponding cost. Add horizontally the total cost of each means of transport. Then add
vertically the total cost of transportation and utilization of the machinery. Lastly, indicate the total amount of incurred expenses in the box entitled TOTAL (3)
Transport
Description
Distance
(in km)
+
+
+
+
Sub-total =
Cost $
Use
Hours
Cost
$
Cost$
+
+
+
+
+
+
+
+
+
TOTAL (3)
=
Sub-total =
SECTION 4 : OTHER COSTS
Use this section to report any other type of expenses incurred for stripping and excavating work. Describe briefly the nature of expenses and enter the
corresponding cost. Finally, add each cost then enter the total amount in the box entitled TOTAL (4).
Description
+
+
+
+
TOTAL (4)
Ministère de l’Énergie et des Ressources naturelles
Service de la gestion des droits miniers
Cost
$
=
Annexe 4 – 2015-11-18 – Page 1 de 2
GREAT TOTAL (TOTAL 1 + 2 + 3 + 4)
Write the total amount of expenses incurred for stripping and excavating work.
This great total must be deferred to section 3 entitled "Identification and work synthesis" and distributed, by title, according to the nature of work
GREAT TOTAL (1 + 2 + 3 + 4) =
SECTION 5: DESCRIPTION OF STRIPPING AND EXCAVATING WORK PER MINING TITLE
In the following columns, inscribe the number of each title subject to mining work and where applicable the stripped surface in square meters (m 2) or the bulk
of soil or excavated rock in cubic meters (m3) on the parcel of land subject to the mining title and detail the dimensions of the surface covered. Lastly, in the
last column, specify the type of land stripped or excavated.
Mining titles n°
Trench n°
(in
m3)
Bulk excavated
(in
Soil
Rock
Nature of ground
Dimensions
m3)
(rock, soil, clay,
sand gravel, etc.)
(in metres)
Length
Width
Depht
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
Ministère de l’Énergie et des Ressources naturelles
Service de la gestion des droits miniers
Annexe 4 – 2015-11-18 – Page 2 de 2
ANNEXE
5
SAMPLING AND ANALYTICAL WORK
SECTION 1 : LABOUR COST
List the name and address of the contractor in charge of carrying out the work program or the name and address of the personnel who participated in the work
as well as the period (year, month, day) during which the work has been carried out . In the last column, inscribe the amounts disbursed for wages to the
personnel or the cost disbursed to the contractor for the carrying out of work. Finally, add each costs and enter the total amount disbursed in box entitled
TOTAL (1)
Identification
Name
Date(s)of performance
Address
Wages or cost
from (year/month/day) to (year/month/day)
$
+
+
+
+
+
+
=
TOTAL (1)
SECTION 2: TRANSPORTATION AND HOUSING OF PERSONNEL AND SUPPLYING COSTS
Detail briefly the type of transportation, housing and supplying. Inscribe the costs incurred for each one such as expenses for truck or vehicle rental,
accomodation, restaurant or grocery shopping, etc.
Moreover, write for each means of transport the distance covered, in kilometers (km) from starting point to arrival point on the site, the number of people
transported as well as the number of days of travelling . Then add each costs and enter the total amount disbursed in the box entitled TOTAL (2)..
Distance
Description
(in km)
Nber of
people
Nber of
days
Cost
$
+
+
+
+
+
+
=
TOTAL (2)
SECTION 3 : SAMPLING AND ANALYTICAL COST
Write the name of the laboratory in charge of analyses, the elements determined, the number of samples analyzed as well as the total weight of samples in
kilograms (Kg), the means of transport used to carry the samples and the distance covered in kilometers (Km). Then in the column entitled COST, write down
the total amount disbursed for each analysis. Finally, add all these amounts and enter the total amount of expenses incurred for analysis in the box entitled
TOTAL (3)
Name of laboratory
Elements determined
Nber of
samples
Weight
(in kg)
Means of Distance
transport (in km)
Cost
$
+
+
+
+
+
+
TOTAL (3)
=
SECTION 4 : OTHER COSTS
Use this section to report any other type of expenses incurred for sampling and analytical work. Describe briefly the nature of expenses and enter the cost in
the column entitled COST. Then add each cost and enter the total amount in box entitled TOTAL (4)
Description
+
+
+
+
+
+
TOTAL (4)
Ministère de l’Énergie et des Ressources naturelles
Service de la gestion des droits miniers
Cost
$
=
Annexe 5 – 2015-11-18 – Page 1 de 2
GREAT TOTAL (TOTAL 1 + 2 + 3 + 4)
Inscribe the amount of expenses disbursed for boring work (drilling).
This great total must be differed to section 3 entitled « Identification and work synthesis » and distributed by title according to the nature of work.
GREAT TOTAL (1 + 2 + 3 + 4) =
SECTION 5: SAMPLING, PREPARATION AND ANALYTICAL METHOD
Describe briefly the method used for sampling, preparing and analyzing the samples.
Description
SECTION 6: DISTRIBUTION OF NUMBER OF SAMPLES PER MINING TITLE
In the following columns, list the number of each title subject to mining work and the number of samples found on the land parcel subject to the title.
Mining title n°
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
Ministère de l’Énergie et des Ressources naturelles
Number of samples
collected
Mining title n°
Number of samples
collected
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
79
Service de la gestion des droits miniers
Annexe 5 – 2015-11-18 – Page 2 de 2
ANNEXE
6
TECHNICAL ASSESSEMENT
OTHER TYPE(S) OF WORK
SECTION 1 : SUMMARY WORK DESCRIPTION
If you carried out a technical assessment or had it done or carried out other type of work (viability study, prospecting, land surveying, etc.), briefly describe
the nature of this work and list the name of people or company who performed them. Moreover, inscribe the period (year, month, day) during which this work
was performed. If during prospecting samples have been collected, complete annex 5.
Date(s) of performance
Description
from (year/month/day) to (year/month/day)
SECTION 2: COST DETAIL
Use this section to detail the expenses incurred. Briefly describe their nature and enter the corresponding cost. Finally, add each cost and enter the total in the
appropriate box.
This total must be deferred to section 3 entitled "Identification and synthesis of work" and be distributed, by title, according to the nature of work.
Description
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
TOTAL
Ministère de l’Énergie et des Ressources naturelles
Service de la gestion des droits miniers
Cost
$
=
Annexe 6 – 2015-11-18 – Page 1 de 1