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MINING AND MILLING
BEFORE THE STATE ENGINEER OF THE STATE OF NEVADA
APPLICATION FOR EXTENSION OF TIME TO PREVENT A FORFEITURE FOR MINING AND MILLING
1. This application is submitted by: , the Permittee Agent
Name of person signing this form
who after being first duly sworn and answering to the best of his/her knowledge the following questions in compliance with the requirements as set forth in the Certificate of Claim:
2. In the matter of permit No.:
Certificate No.:
Claim No.:
Priority date:
3. Nevada Division of Water Resource's (NDWR) Owner(s) of Record on file in the office of the State Engineer:
a. Are you or are you representing the current owner(s) of record of this permit?
Yes
No
b. If, no when did the owner(s) of record change? Month and year:
c. Has a Report of Conveyance been submitted on this permit/claim?
Yes
No
4. Does this Certificate or Claim have multiple owners?
Yes
No
a. If "Yes" on Question 4 is checked, is this request for an extension of time to prevent forfeiture submitted on behalf of all owners?
Yes
No:
b. If "No" on Question 4a is checked, on whose behalf is this extension being filed?
5. Is this mine under a well spacing order from the State Engineer's office?
Yes
No
Order No.
6. If monitoring plan is required, has it been submitted to the State Engineer's office?
Yes
No
7. Give date when the last full beneficial use occurred?
8. How much time is anticipated before full beneficial use will resume?
a. The permittee requests an extension of time for (years) within which to comply with the Certificate or Claim.
9. Explain in detail the reason for non-use.
10. Describe the progress made during the past year as compared to previous years to resume beneficial use.
By checking       pursuant to NRS 53.045, I hereby certify, under penalty of perjury, that the foregoing is true and correct.
Mailing Address
Street or PO Box
City
State
ZIP Code
Phone
Email

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YOU WILL BE PROMPTED FOR A $120 FILING FEE PER YEAR REQUESTED IN THIS APPLICATION FOR EXTENSION OF TIME.
A SEPARATE APPLICATION MUST BE FILED FOR EACH CERTIFICATE OR CLAIM.