ATTACH_5_-_ABANDONED_MINE_LANDS_(AML)_CONTRACTOR_INFORMATION_FORM.pdf

OMB # 1029-0119

Expiration Date:

10/31/2024

ABANDONEDMINELANDS(AML)CONTRACTOR INFORMATIONFORM

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 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.

Instructions for downloading an OFT from the AVS can be found at: https://www.osmre.gov/sites/default/ files/2022-02/OMB_201029-0119_instructions.pdf. If you require assistance you may contact the AVS Office by phone at: 800-643-9748, or by email at: avshelp@osmre.gov.

Part C: Certifying and updating information in the AVS

Select one of the options, follow the instructions for the selected option, sign, and date below.

I, , have express authority to certify that:

(Print Name)

1. Our business is listed in the AVS. The information 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. The information needs to be updated. (If you select this option, you must attach an Entity OFT from the AVS to this form). Complete Part D to provide the missing or corrected information.

3. Our business is not listed in the AVS. The information needs to be added. Complete Part D to provide the information.

Date Signature Title

OMB # 1029-0119

Expiration Date:

10/31/2024 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,VicePresident, Secretary,Treasurer,etc.);

• AllDirectors, Partners, and Members;

• All persons performinga 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 determinethe manner in which the AML reclamation project is being conducted.

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

Name:

Address:

City, State, Zip:

Begin Date:

End Date:

% Ownership:

Position/Title:

Phone Number:

Name:

Address:

City, State, Zip:

Begin Date:

End Date:

% Ownership:

Position/Title:

Phone Number:

Name:

Address:

City, State, Zip:

Begin Date:

End Date:

% Ownership:

Position/Title:

Phone Number:

Name:

Address:

City, State, Zip:

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 30 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, 1849 C Street, NW, Room 4559, Washington, DC 20240.