OMB1029-0119.pdf

OMB # 1029-0119

Expiration Date: 01/31/2019

ABANDONED MINE LANDS (AML) CONTRACTOR INFORMATION FORM

You must complete this form for your AML contracting officer to request an eligibility evaluation from the Office of Surface Mining Reclamation and Enforcement (OSMRE) to determine if you are eligible to receive an AML contract. This requirement applies to contractors and their sub-contractors and can be found under OSMRE’s regulations at 30 CFR 874.16. NOTE: This form must be signed and dated within 30 days of submission to be considered for a current bid.

Part A: General Information

Business Name: _______________________________________________________________ Tax ID #: _______________________________________________________________ Address: __________________________________________________________ City, State, & Zip: __________________________________________________________ Phone Number: __________________________________________________________ Email Address: __________________________________________________________

Part B: Obtain an Organizational Family Tree (OFT) from the Applicant Violator System (AVS)

If you plan to certify the existing AVS information or submit updates under Part C, you must include an OFT.

To obtain an OFT, you may contact the AVS Office at 800-643-9748 or from the AVS website at:

https://avss.osmre.gov/. Instructions for how to download an OFT from the AVS can be found at:

https://www.osmre.gov/programs/AVS/aml-instructions.pdf.

Part C: Certifying and updating information in the AVS

Select only one of the following options, follow the instructions for that option, and sign and date below.

I, _________________________________________, have express authority to certify that:

(Print Name)

1. Our business is in the AVS and is accurate, complete, and up-to-date. If you select this option, you must attach an Entity OFT from the AVS to this form. Do not complete Part D.

2. Our business is in the AVS but needs to be updated. If you select this option you must attach an Entity OFT from the AVS to this form. Use Part D to provide the missing or corrected information.

3. Our business is not in the AVS and needs to be added. Complete Part D.

Date Signature Title https://avss.osmre.gov/ https://www.osmre.gov/programs/AVS/aml-instructions.pdf

OMB # 1029-0119

Expiration Date: 01/31/2019

Part D: OFT Information

Contractor’s Business Name: _____________________________________

If the current Entity OFT information for your business is incomplete in the AVS, or if there is no information in the AVS for your business, you must provide all of the following information as it applies to your business.

Please include additional copies of this page if the space below is not sufficient to capture all information.

• Every officer (President, Vice President, Secretary, Treasurer, etc.);

• All Directors, Partners, and Members;

• All persons performing a function similar to a Director;

• Every person or business that owns 10% or more of the voting stock in your business;

• Any other person(s) who has the ability to determine the manner in which the AML reclamation project is being conducted.

• Please list an end date for any person no longer with your business.

Name: __________________________ Address: __________________________ Begin Date: __________________________ End Date: __________________________ % Ownership: __________________________ Position/Title: __________________________ Phone Number: __________________________

Name: __________________________ Address: __________________________ Begin Date: __________________________ End Date: __________________________ % Ownership: __________________________ Position/Title: __________________________ Phone Number: __________________________

Name: __________________________ Address: __________________________ Begin Date: __________________________ End Date: __________________________ % Ownership: __________________________ Position/Title: __________________________ Phone Number: __________________________

Name: __________________________ Address: __________________________ Begin Date: __________________________ End Date: __________________________ % Ownership: __________________________ Position/Title: __________________________ Phone Number: __________________________

PAPERWORK REDUCTION STATEMENT

The Paperwork Reduction Act of 1995 (44 U.S.C 3501) requires us to inform you that: Federal Agencies may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a current valid OMB control number. This information is necessary for all successful bidders prior to the distribution of AML funds, and is required to obtain a benefit.

Public reporting burden for this form is estimated to range from 15 minutes to one hour, with an average of 25 minutes per response, including time for reviewing instructions, gather and maintaining data, and completing and reviewing the form. You may direct comments regarding the burden estimate or any other aspect of this form to the Information Collection Clearance Officer, Office of Surface Mining Reclamation and Enforcement, Room 203 SIB, Constitution Ave., NW, Washington, D.C. 20240.