Free 1 - Indiana

REPORT OF COAL PRODUCTION AND RECLAMATION FEE
State Form 44984 (R5 / 6-06)

INDIANA DEPARTMENT OF NATURAL RESOURCES DIVISION OF RECLAMATION RR 2 Box 129 Jasonville, IN 47438-9517

Approved by State Board of Accounts, 2004

1. Calendar Quarter Ending: Year

2. Mark "X" in this box if first report for September 30 3b. Permit Expiration Date

March 31
3a. State Permit Number Name of Permittee

June 30



December 31 4a. Federal Mine ID Number



this permit. 4b. Federal Tax ID Number

Mailing Address (number and street, city, state, ZIP code) of Permittee 6. Name of Operator (if other than permittee) Mailing Address (number and street, city, state, ZIP code) LOCATION OF MINE 7. Name of Mine County(s) 8. 9. Type of Mine



Surface



Underground



No surface effects Telephone Number ( )

Name of Contact Person Mined partial quarter

10. STATUS OF MINE PRODUCTION: Mined full quarter 11. EXCESS MOISTURE WEIGHT REDUCTION (a) Total Moisture (b) Inherent Moisture (c) Excess Moisture as (1) or (100 ­ 11a) (2) 11a ­ 11a ­ 11b

Ceased operation
% %

Method Selected


%

[11b X ---------- ]
(100 - 11b)



12. COMPUTATION OF FEE (a) Coal used, Transferred or Sold (Gross) (b) Tonnage Reduction for Excess Moisture (11c x 12a) (c) Tonnage Subject to Fee (12a ­ 12b) (d) Reclamation Fee Due (i) Surface (12c x .055) (ii) Underground (12c x .03) CERTIFICATION
(a) 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.

$ $

(b) Printed or typed name of reporting person (corporate officer, agent of director, on behalf of the operator, or operator) (c) Signature of reporting person (corporate officer, agent of the director, on behalf of the operator, or operator) (d) Date subscribed and sworn to Notary Public Signature of Notary Public Date commission expires

SEAL

IC 14-34-16-6 provides that any person, corporate officer, agent, or director, on behalf of a coal mine operator who knowingly makes any false statement, representation or certification, or knowingly fails to make any statement, representation of certification required in this section shall upon conviction, be punished by a fine of not more than $5,000 or by imprisonment for not more than one year or both.