Fillable Printable Bond Release and Adjustment Transmittal Form - Pennsylvnia
Fillable Printable Bond Release and Adjustment Transmittal Form - Pennsylvnia
Bond Release and Adjustment Transmittal Form - Pennsylvnia
5600-FM-BMP0126 3/2015 COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF MINING PROGRAMS
BOND RELEASE AND ADJUSTMENT TRANSMITTAL FORM
A. APPLICANT:
PERMIT NUMBER:
LICENSE NO.:
TWP.: CO.:
B. PURPOSE
BOND RELEASE CR NO.
BOND ADJUSTMENT
BOND RELEASE TRANSFER TO
BOND RELEASE PERMIT SUPERCEDED BY
OTHER
C. DOWNWARD BOND ADJUSTMENT
BASED ON A RECALCULATION OF LIABILITY THE
BOND AMOUNT MAY BE ADJUSTED AS FOLLOWS:
CURRENT BOND AMOUNT $
BOND LIABILITY REDUCTION $
ADJUSTED BOND LIABILITY $
D. SPECIFY PREFERRED BONDS TO BE RELEASED, IF
APPLICABLE:
ARE THERE REMINING FINANCIAL GUARANTEES
OUTSTANDING?
YES NO
ARE THERE CONVERSION ASSISTANCE FINANCIAL
GUARANTEES OUTSTANDING?
YES NO
E. BOND RELEASE CALCULATION
BOND ADJUSTMENT AMOUNT
STAGE 1 BOND RELEASE AMOUNT
STAGE 2 BOND RELEASE AMOUNT
STAGE 3 BOND RELEASE AMOUNT
NO. OF STAGE 3 ELIGIBLE ACRES
TOTAL OF RELEASE AND ADJUSTMENT
F.
DISTRICT
REVIEWER
APPROVING OFFICIAL
TITLE
DATE
