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