Remediation Bond - Form 3e

Remediation Bond - Form 3.E Department of Mineral Resources Oil and Gas Division 600 East Boulevard Dept 474 Bismark, N.D 58505 to 0614 S.F.N 60068 (11 to 2011)

Field: Surety Company Bond No.

Field: N.D.I.C Bond No.

the Bond Form and the Notary Page Shall Be Printed Or Copied Front To Back Before Signing and Notarizing.

Please Read Instructions Before Filling Out Form.

Please Submit the Original.

Field: N.D.I.C Case Number

Field: Type of Bond (Cash or Surety)

Field: Bond Amount $

In consideration of the agreement between the Principal and the North Dakota Industrial Commission, the Principal and Surety are indebted to the State of North Dakota.

The condition of this obligation is that the principal fully remediate the land affected as determined by the North Dakota Industrial Commission. North Dakota law governs this bond.

Comments

Instructions for signatures: If you are a corporation, use your full corporate name and have a corporate officer sign. If you are a partnership, so state and have at least one general partner sign. If you are an individual doing business under a business name, state your name and your business' name and after your signature, state that you are the sole owner. Any other person signing on behalf of the principal or surety must attach a power of attorney:

Field: Name of Principal

Field: Telephone Number

Field: Address

Field: City

Field: State

Field: Zip Code

Field: Signature

Field: Printed Name

Field: Title

Field: Date

(See Other Side for Notary)

Field: Name of Surety

Field: Telephone Number

Field: Address

Field: City

Field: State

Field: Zip Code

Surety is incorporated in the State of and is authorized to do business in North Dakota.

Field: Signature

Field: Printed Name

Field: Title

Field: Date

(See Other Side for Notary)

Acknowledgement of Principal

Field: State of

Field: County of

Field: Notary Seal

On , known to me to be the person described in and who executed the foregoing instrument, personally appeared before me and acknowledged that (s)he executed the same as a free act and deed.

Field: Notary Public

Field: My Commission Expires

Acknowledgement of Surety

Field: State of

Field: County of

Field: Notary Seal

On , known to me to be the person described in and who executed the foregoing instrument, personally appeared before me and acknowledged that (s)he executed the same as a free act and deed.

Field: Notary Public

Field: My Commission Expires

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Instructions

1. Please refer to Section 43-02-03-15 of the North Dakota Administrative Code regarding bonds.

2. Name of principal shall be the name of the operator and shall be the same as reported on the Organization Report - Form 2 (S.F.N 5748).

3. If not a Surety Bond, a Cash Bond Form 3.D.3 (S.F.N 54259) must be submitted along with this Form 3.E.

4. Comments - Please outline the specifics of your case and site applicable rules.

5. The bond form and the notary page shall be printed or copied front to back before signing and notarizing.

6. The original of this report shall be filed with the Department of Mineral Resources, Oil and Gas Division, 600 East Boulevard, Dept. 474, Bismarck, N.D 58505 to 0614.