Form MO780-0936 "Personal Bond Secured by a Certificate of Deposit" - Missouri

What Is Form MO780-0936?

This is a legal form that was released by the Missouri Department of Natural Resources - a government authority operating within Missouri. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2015;
  • The latest edition provided by the Missouri Department of Natural Resources;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form MO780-0936 by clicking the link below or browse more documents and templates provided by the Missouri Department of Natural Resources.

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Download Form MO780-0936 "Personal Bond Secured by a Certificate of Deposit" - Missouri

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MISSOURI DEPARTMENT OF NATURAL RESOURCES
MISSOURI GEOLOGICAL SURVEY
LAND RECLAMATION PROGRAM
PERSONAL BOND SECURED BY A CERTIFICATE OF DEPOSIT
INCLUDES ASSIGNMENT OF CERTIFICATE OF DEPOSIT
KNOW ALL MEN BY THESE PRESENTS, That the undersigned
(NAME OF PERMITTEE)
,
of
as Obligator (permittee), is
(MAILING ADDRESS OF PERMITTEE)
held and firmly bound unto the state of Missouri payable to the Treasurer of the state of Missouri, to the credit of the Mined Land
Reclamation Fund in the penal sum of
Dollars, $
for the payment of such sum, well and
truly to be made, we jointly and severally bind to ourselves, our heirs, administrators, executors, successors and assigns. This
obligation is secured by Certificate of Deposit as described herein.
CERTIFICATE NUMBER
ISSUING BANK
AMOUNT
DATED
PHONE NUMBER WITH AREA CODE
ISSUING BANK ADDRESS
CERTIFICATE NUMBER
ISSUING BANK
AMOUNT
DATED
PHONE NUMBER WITH AREA CODE
ISSUING BANK ADDRESS
CERTIFICATE NUMBER
ISSUING BANK
AMOUNT
DATED
PHONE NUMBER WITH AREA CODE
ISSUING BANK ADDRESS
Each Certificate of Deposit described above is payable to the Treasurer of the State of Missouri or
(Obligator), is assigned in full to the State of Missouri, Land Reclamation Program and shall be kept in the custody of the State of
Missouri until successful completion of the conditions of this obligation, and shall be forfeitable by the State of Missouri, acting through
the Land Reclamation Program, if the conditions of this obligation are not met. The issuing bank(s) name above hereby waives all
rights of setoff or liens against the Certificate(s) of Deposit denominated above.
THE CONDITION OF THIS OBLIGATION IS SUCH, That whereas the above named Obligator did on the ____ day of ___________ ,
20____ file with the Land Reclamation Program an application to secure a permit to engage in surface mining and reclamation
operations in the State of Missouri, under terms and provisions of Sections 444.760 to 444.789, RSMo; that said application has been
approved for operations under Permit Number _______________ consisting of ____________ acres; that the Obligator will undertake
operations and complete reclamation on the affected land in accordance with statutes, regulations, of the Program, conditions of the
permit, and the approved reclamation plan; and that this bond is held as security for reclamation responsibilities incurred by the
permittee and is subject to forfeiture pursuant to the statutes and regulations for failure to comply. The penalty of this b ond shall be the
full effective amount of this bond.
Now if the Obligor faithfully performs all the requirements of Sections 444.760 to 444.789, RSMo, and complies with the regulations of
the Land Reclamation Program at 10 CSR Division 40, with the conditions of the permit issued to Obligor as identified herein, or any
amendments to said permit, and successfully completes reclamation on the area covered by said permit according to said statutes,
regulations, permit conditions and reclamation plan, then this obligation shall be null and void; otherwise, it shall remain in full force
and effect. Application for release of the obligation of this bond may be made to the Land Reclamation Program in accordance with
the provisions of Section 444.760 and 444.789, RSMo.
PERMIT NUMBER
PERMITTEE
Submit all forms to:
Missouri Department of Natural Resources
Phone: 573-751-4041
Land Reclamation Program
Fax: 573-751-0534
PO Box 176
Website:
www.dnr.mo.gov
Jefferson City, MO 65102-0176
MO 780-0936 (12-15)
Page 1
MISSOURI DEPARTMENT OF NATURAL RESOURCES
MISSOURI GEOLOGICAL SURVEY
LAND RECLAMATION PROGRAM
PERSONAL BOND SECURED BY A CERTIFICATE OF DEPOSIT
INCLUDES ASSIGNMENT OF CERTIFICATE OF DEPOSIT
KNOW ALL MEN BY THESE PRESENTS, That the undersigned
(NAME OF PERMITTEE)
,
of
as Obligator (permittee), is
(MAILING ADDRESS OF PERMITTEE)
held and firmly bound unto the state of Missouri payable to the Treasurer of the state of Missouri, to the credit of the Mined Land
Reclamation Fund in the penal sum of
Dollars, $
for the payment of such sum, well and
truly to be made, we jointly and severally bind to ourselves, our heirs, administrators, executors, successors and assigns. This
obligation is secured by Certificate of Deposit as described herein.
CERTIFICATE NUMBER
ISSUING BANK
AMOUNT
DATED
PHONE NUMBER WITH AREA CODE
ISSUING BANK ADDRESS
CERTIFICATE NUMBER
ISSUING BANK
AMOUNT
DATED
PHONE NUMBER WITH AREA CODE
ISSUING BANK ADDRESS
CERTIFICATE NUMBER
ISSUING BANK
AMOUNT
DATED
PHONE NUMBER WITH AREA CODE
ISSUING BANK ADDRESS
Each Certificate of Deposit described above is payable to the Treasurer of the State of Missouri or
(Obligator), is assigned in full to the State of Missouri, Land Reclamation Program and shall be kept in the custody of the State of
Missouri until successful completion of the conditions of this obligation, and shall be forfeitable by the State of Missouri, acting through
the Land Reclamation Program, if the conditions of this obligation are not met. The issuing bank(s) name above hereby waives all
rights of setoff or liens against the Certificate(s) of Deposit denominated above.
THE CONDITION OF THIS OBLIGATION IS SUCH, That whereas the above named Obligator did on the ____ day of ___________ ,
20____ file with the Land Reclamation Program an application to secure a permit to engage in surface mining and reclamation
operations in the State of Missouri, under terms and provisions of Sections 444.760 to 444.789, RSMo; that said application has been
approved for operations under Permit Number _______________ consisting of ____________ acres; that the Obligator will undertake
operations and complete reclamation on the affected land in accordance with statutes, regulations, of the Program, conditions of the
permit, and the approved reclamation plan; and that this bond is held as security for reclamation responsibilities incurred by the
permittee and is subject to forfeiture pursuant to the statutes and regulations for failure to comply. The penalty of this b ond shall be the
full effective amount of this bond.
Now if the Obligor faithfully performs all the requirements of Sections 444.760 to 444.789, RSMo, and complies with the regulations of
the Land Reclamation Program at 10 CSR Division 40, with the conditions of the permit issued to Obligor as identified herein, or any
amendments to said permit, and successfully completes reclamation on the area covered by said permit according to said statutes,
regulations, permit conditions and reclamation plan, then this obligation shall be null and void; otherwise, it shall remain in full force
and effect. Application for release of the obligation of this bond may be made to the Land Reclamation Program in accordance with
the provisions of Section 444.760 and 444.789, RSMo.
PERMIT NUMBER
PERMITTEE
Submit all forms to:
Missouri Department of Natural Resources
Phone: 573-751-4041
Land Reclamation Program
Fax: 573-751-0534
PO Box 176
Website:
www.dnr.mo.gov
Jefferson City, MO 65102-0176
MO 780-0936 (12-15)
Page 1
CERTIFICATE OF DEPOSIT HOLDER(S)
NOTE:
1.
Must be signed and notarized by all individuals listed on Certificates of Deposit. Attach proper acknowledgments for all
signatures.
2.
Interest on the Certificates of Deposit may be payable to the Obligor.
3.
No Single Certificate of Deposit shall exceed the sum of $250,000 nor shall any permittee submit Certificates aggregating
more than $250,000 from a single bank. The issuing bank(s) must be protected by the Federal Deposit Insurance
Corporation (F.D.I.C.)
4.
The Certificate of Deposit shall be kept in the custody of the State of Missouri until successful completion of the conditions of
this obligation, and shall be forfeitable by the State of Missouri, acting through the Land Reclamation Program, if the
conditions of this obligation are not met.
5.
Must notify the State of Missouri, Land Reclamation Program if the name of the financial institution has changed.
SIGNATURE OF OBLIGOR
DATE
NOTARY PUBLIC EMBOSSER SEAL
STATE
COUNTY (OR CITY OF ST. LOUIS)
SUBSCRIBED AND SWORN BEFORE ME, THIS
DAY OF
YEAR 20
NOTARY PUBLIC SIGNATURE
MY COMMISSION EXPIRES RUBBER STAMP CLEAR AREA BELOW
NOTARY PUBLIC NAME(TYPED OR PRINTED)
SIGNATURE OF OTHER INDIVIDUALS LISTED ON THE CD
DATE
NOTARY PUBLIC EMBOSSER SEAL
STATE
COUNTY (OR CITY OF ST. LOUIS)
SUBSCRIBED AND SWORN BEFORE ME, THIS
DAY OF
YEAR 20
NOTARY PUBLIC SIGNATURE
MY COMMISSION EXPIRES RUBBER STAMP CLEAR AREA BELOW
NOTARY PUBLIC NAME (TYPED OR PRINTED)
ISSUING BANK
Note: Signature must be notarized. The issuing bank acknowledges this assignment and agrees to waive the rights of lien or set offs
against these certificates of deposit until released by the Land Reclamation Program. Should the Missouri Mining Commission order
the forfeiture of these certificate(s) of deposit pursuant to 10 CSR 40-10.030(10), the issuing bank agrees to waive any early
withdrawal fees and interest penalty.
BANK NAME
PRINTED NAME AND TITLE OF SIGNATORY
DATE
AUTHORIZED SIGNATURE
NOTARY PUBLIC EMBOSSER SEAL
STATE
COUNTY (OR CITY OF ST. LOUIS)
SUBSCRIBED AND SWORN BEFORE ME, THIS
DAY OF
YEAR 20
NOTARY PUBLIC SIGNATURE
MY COMMISSION EXPIRES RUBBER STAMP CLEAR AREA BELOW
NOTARY PUBLIC NAME (TYPED OR PRINTED)
FOR DEPARTMENT USE ONLY
BOND ACCEPTED BY THE DIRECTOR (SIGNATURE)
DATE
PERMIT NUMBER
MO 780-0936 (12-15)
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