Official Use
State Form 51509 (11-03) Approved by State Board of Accounts 2004 BP-1
INDIANA DEPARTMENT OF NATURAL RESOURCES DIVISION OF RECLAMATION SURFACE COAL MINE RECLAMATION BOND POOL FUND REPLACEMENT
Name and Address of Permittee: Bond Pool Identification Number:
(This form is to be used when a company enters the bond pool with acreage previously bonded by conventional bond.) Pit Name: Bond Segment: or Area: Permit Number: Bond Rate/acre:
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, ...) Status of Bonded Acres: Grading Acres: Revegetation Acres: Final Acres: Fee Submitted with this Segment: Original Released Current
PHASE I BOND
Phase I Bond Calculation (submitted this segment): Bond Company: Bond Number:
BOND POOL
Phase II Bond Calculation: Phase III Bond Calculation: TOTAL BOND POOL THIS SEGMENT:
Signature: Title: Date: Accepted:
Date
Signature:
Delegate, Division of Reclamation, Department of Natural Resources