Free 51895.pdf - Indiana

APPLICATION FOR SELF-BONDING
State Form 51895 (2-05)

INDIANA DEPARTMENT OF NATURAL RESOURCES DIVISION OF RECLAMATION

SELF-BOND NO. Initial Application for Self-Bonding (Applicant or Corporate Guarantor )

Attach additional pages as needed and reference form item number to which addition(s) apply. If application for Corporate Guarantor, Name of Applicant: 1. Identification of Applicant/Guarantor a) For Corporations ONLY: Name:

Address:

Telephone: Site of Incorporation: Principal Place of Business:

List of Corporate Officers:

Name, Title, and Authority of Person signing this application (Attach Certificate of Authority by Board of Directors):

Certification of Authority to do business in Indiana:

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INDIANA DEPARTMENT OF NATURAL RESOURCES DIVISION OF RECLAMATION APPLICATION FOR SELF-BONDING

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If Corporation is wholly owned subsidiary or if more than 10% of stock is owned by one enterprise, detail ownership:

b) For all other forms of business enterprise: Name:

Address:

Telephone: Statement of Enterprise Organization:

List of Principals:

Law of State under which enterprise formed:

Principal place of business: Relationship and authority of person signing this application (If person signing is not a principal, attach certification, from a principal, of the agent's signing authority.):

INDIANA DEPARTMENT OF NATURAL RESOURCES DIVISION OF RECLAMATION APPLICATION FOR SELF-BONDING

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2.

a) Amount that is proposed under the self-bond (this plus all other outstanding and proposed surface coal mining and reclamation self-bonds may not exceed 25% of a coal operator's/guarantor's tangible net worth in the United States.): A brief description and chronological history of those operations of the applicant conducted within the last five years that would demonstrate a continuous operation:

3.

Financial Statements in detail, to include: a) Audited applicant's/guarantor's balance sheet and income statement for the most recently completed fiscal year. b) Un-audited financial statements for completed quarters of the current fiscal year.

4.

A report prepared by an independent certified public accountant in conformity with generally accepted accounting principles, and containing the accountant's audit opinion or review opinion of the financial statements with no adverse opinion. The report should detail which one or more of the following criteria are met by the applicant. a) The applicant has a current rating for its most recent bond issuance of "A" or higher as issued by either Moody's Investor Service or Standard and Poor's Corporation (identify the rating service together with any further breakdown of specific ratings). b) The applicant has a tangible net worth of at least $10,000,000.00 (ten million dollars), a ratio of total liabilities to net worth of 2.5:1 or less, and a ratio of current assets to current liabilities of 1.2:1 or greater. c) The applicant's fixed assets in the United States total at least $20,000,000.00 (twenty million dollars) and the applicant has a ratio of total liabilities to net worth of 2.5:1 or less, and a ratio of current assets to current liabilities of 1.2:1 or greater.

5.

List the dollar value of this proposed self-bond plus all other outstanding and proposed self-bonds for surface coal mining and reclamation operations in the U.S.

INDIANA DEPARTMENT OF NATURAL RESOURCES DIVISION OF RECLAMATION APPLICATION FOR SELF-BONDING

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6. 7.

Tangible net worth in the United States: A statement listing any notices issued by the Securities and Exchange Commission or proceedings initiated by any party alleging a failure to comply with any public disclosure or reporting requirement under the securities laws of the United States. Such statement shall include a summary of each allegation, including the date, the requirement alleged to be violated, the party making the allegation, and the disposition or current status thereof. Registered office for service on the applicant of notices, processes, or demands: Name:

8.

Address:

Telephone: 9. Registered agent for service on the applicant of notices, processes, or demands: Name:

Address:

Telephone: **NOTE: Any change in the registered agent or office must be filed immediately with the Division of Reclamation.

10.

Attach the indemnity agreement executed by all parties bound to the self-bond agreement to pay all litigation costs. The applicant is hereby advised that, if its application is approved, and self-bond or corporate guarantee is accepted, that acceptance is continually contingent upon the permittee and corporate guarantors compliance with the information update requirements of IC 13-4.1-6.3-12 and IC 13-4.1-6.3-13.

11.

INDIANA DEPARTMENT OF NATURAL RESOURCES DIVISION OF RECLAMATION APPLICATION FOR SELF-BONDING

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Signature Page

I, (typed or printed name of responsible official or applicant's legal representative), hereby affirm that all statements and representations made in this application and attachments thereto are true and correct and that I am duly authorized to sign this application of behalf of

Applicant:

Signed:

Title:

(Attach a copy of power of attorney or resolution of Board of Directors that grants signature authority.)

Subscribed and sworn to before me this

day of

,

.

My commission expires

.

Notary Public Signature

Name typed or printed

Residence: County

State