5600-FM-BMP0411 Rev. 1/2014
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF MINING PROGRAMS
7C-FA-15.0
PARTIAL REPLACEMENT OF COLLATERAL
UNDER COLLATERAL BOND — MINING
License No.
Permit No.
(Department Use Only)
This Endorsement is attached to and intended to become made a part of the Collateral Bond — Mining (the
“Collateral Bond”) dated
, submitted pursuant to Permit
No.
originally issued on
,
by
.
(Name of Mine Operator)
The Operator hereby agrees to deposit the following collateral:
Name of
Bank/Govt. Issuer
Type of
Collateral
Collateral
ID No.
Dollar
Amount
Market Value
1.
2.
3.
to replace the following existing collateral on deposit with the Department pursuant to the Collateral Bond:
Name of
Bank/Govt. Issuer
Type of
Collateral
Collateral
ID No.
Dollar
Amount
Market Value
1.
2.
3.
The replacement collateral shall secure the Collateral Bond, which assumes and covers any and all liability and
obligations accrued and to be accrued under the Law (as defined in the Collateral Bond) from the above permit issuance
date until such time as the Department shall release, in writing, the Collateral Bond of such liability and obligations. In
consideration of the pledge and deposit of the replacement collateral, the Department will release the said existing
collateral identified above of any and all liability under the Law.
-1-
5600-FM-BMP0411 Rev. 1/2014
this
IN WITNESS WHEREOF, the Operator hereunto sets its hand and seal, intending to be legally bound hereby,
day of
, 20 .
OPERATOR:
(Print Operator Name)
:
By:
(Signature and Title)
By:
(Signature and Title)
Approved as to legality and form:
Preapproved
6/11/13
Office of Attorney General
Preapproved
5/3/13
Office of General Counsel
Chief/Assistant Counsel - Department of Environmental Protection
Approved for the Department:
Bureau of Office Services
-2-
(Seal)
5600-FM-BMP0411 Rev. 1/2014
ACKNOWLEDGEMENT
COMMONWEALTH /STATE OF
:
COUNTY OF
:
A
TO BE USED BY AN OPERATOR THAT IS A CORPORATION, PARTNERSHIP, LIMITED LIABILITY COMPANY
or MUNICIPAL AUTHORITY
On
,
and
(Date)
(Name)
], personally appeared before me, and identified
(Name)
(himself, and/or herself or themselves – please CIRCLE what is accurate) as the
[and
, respectively,]
(Title)
(Title)
of
,
(Name of Operator – must be identical to Operator identified in Bond)
Each affiant stated that, in accordance with (1) Please CIRCLE ONE AND ONLY ONE [the bylaws of the corporation or
Municipal Authority] the Partnership Agreement] [the Operating Agreement of the LLC or the LLP] and/or (2) any other
documents that state who is authorized to act on behalf of the Operator, the affiant was authorized to sign the attached
Bond on behalf of the Operator
B
TO BE USED BY AN OPERATOR THAT IS AN INDIVIDUAL
On
(Date)
(Name)
Personally appeared before me, and acknowledged that he or she executed the attached Bond for the purposes therein
contained.
IN WITNESS WHEREOF, I have hereunto set my hand and official seal.
(SEAL)
My Commission Expires:
(Notary Public Signature)
(Date)
-3-