6_B13._AMLContractorForm.pdf

OMB #1029-0119

Expiration Date: 1/31/19

AMLCONTRACTORINFORMATIONFORM

You must complete this form for your AML contracting officer to request an eligibility evaluation from the Office of Surface Mining Reclamationand Enforcement to determine if you are eligible to receive an AML contract. This requirement applies to contractors and their sub-contractors and is found under OSMRE’s regulations at 30 CFR 874.16. When possible, please type your information onto this form to reduce errors on our end. NOTE: Signature and date this form is signed must be recent (within the last month) to be considered for a current bid.

Part A: General Information.

BusinessName:

Tax Payer ID No.:

Address:

City: State: Zip Code: Phone:

Fax No.:

E-mail address:

Part B: Obtain an Organizational Family Tree (OFT) from the 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 fromthe AVS website at https://avss.osmre.gov/ . Instructions on how to download an OFT from the AVS can be found at http://www.osmre.gov/programs/AVS/aml-instructions.pdf.

Part C: Certifying and updating information in the Applicant/Violator System (AVS).

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

I, , have the express authority to certify that:

(Printname)

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. Sign and date below and do not completePart

D.

2. Our business is in the AVS and 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 missingor correctedinformation.

Sign and date below and complete Part D.

3. Our business needs to be added in order to confirm our eligibility to receive an AML Contract.

If you select this option, you must provide all information required in Part D.

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

Part D: OFT Information.

Contractor’sBusinessName:

If the current Entity OFT information for your business is incomplete or incorrect in theAVS, or if there is no information in theAVS for your business, you must provide all of the following information as it applies to your business. Please make as many copies of this page as you require.

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 provide an ending date for anyone on your attached OFT that is no longer with your business.

Name Position/Title

Address Telephone #

% of Ownership

Begin Date: Ending Date:

Name

Address

Begin Date:

Position/Title

Telephone #

% of Ownership

Ending Date:

Name

Address

Begin Date:

Position/Title

Telephone #

% of Ownership

Ending Date:

Name

Address

Begin Date:

Position/Title

Telephone #

% of Ownership

Ending Date:

PAPERWORKREDUCTIONSTATEMENT

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 currently 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 1 hour, with an average of

22 minutes per response, including time for reviewing instructions, gathering 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 202 SIB, Constitution Ave.,NW, Washington, D.C. 20240.