U.S. Department of the Interior Bureau of Land Management California State Office RECORDING REQUESTED BY AND MAIL TO: (Please type or use black ink on this form) S R U PAGE SIZE DA MISC LONG RFD COPY M A L 465 426 PCOR NCOR SMF NCHG CTY UNI Name Address T: EXAM FOR RECORDER’S USE ONLY No. of claims X $5/claim = Total due BLM$ AFFIDAVIT OF LABOR To whom it may concern, please take notice that: 1. Certain labor and improvements required by law were performed or made on, or for the benefit of, the following mining claim or claims (which together comprise a group of contiguous claims) in the County of , California, in the mining assessment year ending September 1, . Name of Mining Claim Location by S/T/R/Mer. Example: 29/9N/14E/SBM / / / / / / / / County Recordation Data (Write in Instrument or Book and Page No.) CAMC No. Original Recordation Date Last Amendment Date / / / / (If more space is needed use supplemental sheet) 2A. Type of labor and improvements (specify what was done and give the total value for that labor and improvements – at least $100 for each claim). If a geological, geochemical, or geophysical survey was performed, as per 30 U.S.C. 28-1, reference title of report of survey in question, give cost and date of the survey and report, and indicate it was filed with the County Recorder. TAX COLLECTOR USE Description Value Total Value Affidavit of Labor Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com 2B. Date(s) the assessment work was performed (month) (day(s)) (year) 3. Name(s) and address(es) of Person(s) who performed the labor and improvements: Name(s) (print) Current Mailing or Residence Address (print) 4. Name(s) and address(es) of person(s) who hold and claim subject mining claim(s) for the valuable mineral(s) contained therein: Name(s) (print) Current Mailing or Residence Address (print) 5. The undersigned testify that on the original location date of , , all monuments required by law were erected upon the subject claim(s), and all notices required by law were posted on the subject claim(s) or copies thereof were in place, and at said date each corner monument bore or contained marking sufficient to appropriately designate the corner of the claim to which it pertains and the name of the claim(s). I (we) hereby certify under penalty of perjury under the laws of the State of California that the foregoing statements are true and correct: , Date (Signature of person(s) responsible for above statements) FILE THIS ORIGINAL NOTICE WITH APPROPRIATE COUNTY RECORDER (BY September 30) AND FILE A DUPLICATE NOTICE (by December 30) WITH THE BUREAU OF LAND MANAGEMENT, CALIFORNIA STATE OFFICE, FEDERAL OFFICE BUILDING, ROOM E-2845, 2800 COTTAGE WAY, SACRAMENTO, CALIFORNIA 95825-1889. Any person who willfully makes a false statement with respect to any mining claim on the affidavit of labor or improvements or on the supplementary affidavit is guilty of a misdemeanor, and upon conviction shall be punished by a fine of not more than two hundred dollars ($200) or by imprisonment in the county jail for not more than six months, or by both the fine and imprisonment. (Public Resources Code of California, Div. 3.5, Chap. 1, Sec. 3913c,d). This form is for the purpose of complying with the laws of the United States and the State of California pertaining to assessment work (30 USC 28, 43 CFR 3833.2). Subject to Paperwork Reduction Act and Privacy Act statements available at the BLM California State Office, Sacramento. Affidavit of Labor Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com