���� MAINTENANCE (RENTAL) FEE PAYMENT FORM
USDI Bureau of Land Management, 2800 Cottage Way, Room W1834, Sacramento, CA 95825 The Mining Claim Maintenance (Rental) Fees of $125 per claim or site may be paid by cash, check, money order, or credit card (VISA or MasterCard). Payments should be mailed to the Bureau of Land Management at the address above. Allow sufficient mailing time so that your payment will be received in our office by the due date of September 1.� If you wish to pay by telephone using your credit card, please call BLM at (916) 978-4400 or (916) 978-4360. If paying by phone, please have all information that will be requested in order before you place your call.� CLAIMANT NAME: ______________________________________________� ADDRESS:��������������� ______________________________________________� ��������������������������������� ______________________________________________�
�� Claim Name(s) | CAMC Numbers | � | � | � | � | � | � | � | � | � | � | � | � | � | � | � | � | � | � |
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----------------------------Additional claims & CAMC #s can be listed on a separate page.---------------------------- IF USING A CREDIT CARD, COMPLETE THE FOLLOWING:� Number of Claims ________X $125 = $________ as maintenance fee payment for year _____.�
EXACT NAME
ON CREDIT CARD: ________________________________________________________� Amount Paid: $________________����� Circle one:�����VISA��������� MASTERCARD�� CREDIT CARD NUMBER: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __�� Expiration Date: _________________ Telephone: (����� )____________________�� Signature: ____________________________________________________________�
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Title 18 USC Section 1001, makes it a crime for any person knowingly and willfully providing any department or agency of the United States any false, fictitious or fraudulent statement or representation as to any matter within its jurisdiction.� | 
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