AVS FORM ARQM DEP25-22-AML Northern Jetting and Vacuum Truck Services Region 2.pdf

Office of Surface Mining Reclamation and Enforcement

Instructions for Completing the AML Contractor Form OMB #1029-0119

Purpose: The Office of Surface Mining Reclamation and Enforcement Applicant/Violator System (AVS) office is required to conduct eligibility checks for businesses performing abandoned mine land (AML) reclamation work to ensure those businesses are not associated with any coal mining violations in accordance with the Surface Mining Control and

Reclamation Act (SMCRA). This form is used to update the AVS database which maintains relationship information between individuals and their associated businesses. If you have any questions, please contact the AVS Office at 800-643-

9748.

Part A: General Information: Part A should be completed by the AML Contractor. You can find an electronic fillable form on our website (https://www.osmre.gov/programs/regulating-coal-mines/avs).

Part B: Obtain an Organizational Family Tree (OFT): Part B should be completed by the AML Contractor. An

Organizational Family Tree (OFT) indicates the relationships between individuals and their associated business.

You can obtain an OFT two ways:

1. Call the AVS Office at 800-643-9748 to request your company’s OFT.

2. Go to the AVS website (https://avss.osmre.gov). Click “Access AVS”, and then “Login as Guest”. Place your cursor on the “Entity” Module and click. Type your business name (or entity number) in search box and press enter. Select your company and then click on the “Relationship” tab to display your Entity OFT information. Print the Entity OFT from AVS. Review the OFT, if you need to make updates complete Part D.

Attach the OFT to your AML Contractor Form.

If you are a new company or this is your first AML bid: Your business is most likely not in the AVS. If your company does not appear in the AVS database, move on to Part C, check Box 3, and complete Part D of this form.

If your company has worked on previous AML projects or in the coal mining industry: Your business is most likely in the

AVS, but may need to be updated. Obtain and review your OFT and then complete Part C.

Part C: Certifying and updating information in the Applicant/Violator System (AVS). Part C should be completed by the AML Contractor. Please check the box that best describes your situation, sign and date.

Note: Signature date must be recent (within 30 days) to be considered.

Part D: OFT Information. Part D should be completed by the AML Contractor only if you want to make updates to what information is in the AVS, or if your company does not have any information in the AVS. Include all fields, including the relevant begin and/or end dates for individuals, including middle name or initial for individuals if possible.

Answers to Part D FAQs:

Which employees should be included in Part D?

Any current or separated employee of significance should be listed. Refer to the list provided at the top of Part D.

For those owning less than 10% reporting the ownership is optional. Include those employees who direct, manage, or control the project. If, for example, a Professional Engineer has the power to determine how the project is conducted you should include him/her on Part D.

What address and phone number should I use?

Use the address and phone number where the person receives business correspondence.

What are the begin and end dates for?

Begin dates indicate when a person started in that position in your company. If an individual still works at the company you can simply fill in the begin date and leave the end date blank or write “N/A”. End dates are used for indicating that someone no longer works in that capacity or is no longer employed at the company. If an employee has held more than one position or title, note the begin dates/end dates for each position.

https://www.osmre.gov/programs/regulating-coal-mines/avs https://avss.osmre.gov

OMB # 1029-0119

Expiration Date:

01/31/2028

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%20instructions.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:

01/31/2028 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.