Fillable Printable Collateral Assignment Ca 1

Collateral Assignment Ca 1

COLLATERAL ASSIGNMENT OF

DEPOSIT ACCOUNT

State form 50624 (R3 / 12-11)

Form DA-1

Instructions: Submit one (1) original and one (1) copy

Note:

No individual deposit nor the total of all deposits of the assignor at any individual savings institution shall exceed $100,000 or the

maximum insurable amount by F.D.I.C. or F.S.L.I.C. All deposit pledged to the Department of Natural Resources as performance

bond under I.C. 14-34 will be valued at current market value and not face value. The current market value is the face value of the

deposit less any penalties for early withdrawal.

Part I

(To be completed by Assignor)

responsible official for

(Name and Address of Permittee) (number and street, city, state, and ZIP code)

hereby assign, transfer to and pledge with the Director of the Indiana Department of Natural Resources all right, title, and interest in and

to the Deposit Account issued by or carried with

(Name of Bank or Savings Institution)

Account number

in the face amount of $

, except that all interest

This Assignment is made as, and shall constitute, collateral bond for the faithful performance of the assignor's obligations under I.C.

14-34, 312 IAC 25, and any conditions of the permit to which this Assignment is applicable.

Liability under this Assignment is for the duration of surface coal mining and reclamation operations conducted at

, and continues thereafter for a period coincident with the assignor's

(Pit Name)

responsibility for the establishment of revegetation on the affected areas pursuant to 312 IAC 25-6-59, 60, 61 and 312 IAC 25-6-120,

121, 122, unless replacement bond acceptable to the Director of the Indiana Department of Natural Resources has been submitted.

FOR OFFICIAL USE

INDIANA DEPARTMENT OF NATURAL RESOURCES

DIVISION OF RECLAMATION

14619 W. State Road 48

Jasonville IN 47438

Page 1 of 3

(Address of Bank or Savings Institution) (number and street, city, state, and ZIP code)

accrued or accruing hereafter on said Account is to remain the property of the assignor.

(Permit Number)

This Account was established on

with

acting as Trustee for said Account. The Trustee has been appointed to ensure that this Account is preserved in accordance with all

terms and conditions of this Assignment. The undersigned hereby agree that no modifications shall be made to any of the terms or

conditions of the Trust Agreement without prior written authorization from the Director of the Indiana Department of Natural Resources.

(Name of Bank or Savings Institution)

(date) (month, day, year)

Print Form

Page 2 of 3

DATE (month, day, year)

(Title)

(Assignor)

SIGNATURE

(Title)

(Assignor)

SIGNATURE

NAME OF PERMITTEE

The undersigned further presents and warrants that any assignments of this Account made while this Assignment is n effect shall be

secondary to this Assignment.

The undersigned presents and warrants that the Account is genuine and is in all respects what it purports to be; that the undersigned is

the owner thereof free and clear of all liens and encumbrances of any nature whatsoever; and that the undersigned has full power,

right, and authority to execute and deliver this Assignment.

The undersigned hereby constitutes and appoints the Director of the Indiana Department of Natural Resources as the true and lawful

attorney of the undersigned to demand, collect, and receive all amounts, excluding interest, which shall become due under the terms of

this Assignment, and to endorse all documents for payment or negotiation and to endorse any commercial paper given in payment of

the Account.

This institution understands and agrees that the procedures governing the forfeiture of this Account are specified in 312 IAC 25-5-17

and 25-5-18, and that, upon due presentation of a copy of Division of Reclamation "Notification of Bond Forfeiture" form stating that the

Indiana Department of Natural Resources has forfeited bond for the permit to which this Assignment is applicable, this institution will

forward to the Indiana Division of Reclamation within five (5) days, a bank draft in the amount of the face value of this Account less any

penalties for early withdrawal. The maximum penalty for early withdrawal of this Account is: $ .

This institution undertakes to save and hold harmless the Indiana Department of Natural Resources and the State of Indiana from all

loss, claims, and litigation which this institution may suffer in consequence of its acting in reliance upon, and pursuant to, this

Assignment.

The signature(s) of the assignor(s) appearing on PART I of this document was (were) made in the presence of the undersigned officer

of the financial institution and their signatures are herewith guaranteed by it.

SIGNATURE GUARANTEE AND UNDERTAKING BY THE FINANCIAL INSTITUTION

(To be completed by Bank or Savings Institution)

Part II

This institution herein states that it has no other interests in this Account other than its sole responsibility to act as Trustee to hold such

deposits and pay to the Assignor any and all interest accruing under this Account. This institution agrees that any claim or lien, which

may result from this escrow arrangement or which, as Trustee or as the escrow bank, it may acquire in the future against the

Assignor(s), will be secondary and junior to the Department's interest in this Account.

This institution understands that this Account is being pledged to the State of Indiana, Department of Natural Resources, Division of

Reclamation by the Assignor as bond under I.C. 14-34 and that a proper record of this assignment has been made on the books of this

institution.

The total amount of this Account and all other deposits of the assignor(s) at this institution does not exceed $100,000 or the maximum

insurable amount as determined by F.D.I.C. or F.S.L.I.C.

This institution agrees that no modification will be made to the terms and conditions of this Account such that the interest of the Indiana

Department of Natural Resources under this assignment will be jeopardized, or in any manner affected, without first notifying and

obtaining the approval of the Director of the Indiana Department of Natural Resources. Notice of any proposed modification or change

in the terms or conditions of this Account will be given to the Director of the Indiana Department of Natural Resources.

Page 3 of 3

(Date) (month, day, year)

(Name typed or printed)

(Signature)

(Name of Financial Institution)

(Title)

Accepted by:

(Delegate, Indiana Division of Reclamation)

(Date) (month, day, year)