Free Official Use - Indiana


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Date: May 31, 2005
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State: Indiana
Category: Government
Author: maddoxt
Word Count: 153 Words, 1,003 Characters
Page Size: Letter (8 1/2" x 11")
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http://www.state.in.us/icpr/webfile/formsdiv/51510.pdf

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Form BP-2
State Form 51510 (11-03) Approved by State Board of Accounts 2004

Official Use

INDIANA DEPARTMENT OF NATURAL RESOURCES DIVISION OF RECLAMATION SURFACE COAL MINE RECLAMATION BOND POOL FUND
Name and Address of Permittee: Bond Pool Identification Number:

(This bond request supersedes all other bond pool liability dedicated to this permit.) Pit Name: Bond Segment: Acres Added (this Segment): or Area: Permit Number: Bond Rate/acre: Total Acres in Pool (this Permit):

FEES
(I.C. 14-34-8-8(a) the operator shall pay a fee of twenty-five dollars ($25) per bonded acre in the fund, ...) Fee Submitted with this Segment:

PHASE I BOND
Phase I Bond Calculation (submitted this addition): Bond Company: Bond Number:

BOND POOL
Phase II Bond Calculation: Phase III Bond Calculation: Phase II and Phase III Currently Held: TOTAL BOND POOL THIS PERMIT:

Signature:
Authorized Representative

Title: Date: Accepted:
Date

Signature:
Delegate, Division of Reclamation, Department of Natural Resources