Form DMM-167 "Surety Bond Rider" - Virginia

What Is Form DMM-167?

This is a legal form that was released by the Virginia Department of Mines, Minerals and Energy - a government authority operating within Virginia. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2016;
  • The latest edition provided by the Virginia Department of Mines, Minerals and Energy;
  • 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 printable version of Form DMM-167 by clicking the link below or browse more documents and templates provided by the Virginia Department of Mines, Minerals and Energy.

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Download Form DMM-167 "Surety Bond Rider" - Virginia

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DIVISION OF MINERAL MINING
900 NATURAL RESOURCES DRIVE, STE 400
CHARLOTTESVILLE, VA 22903
(434) 951-6310
Permit Number:
Bond:
SURETY BOND RIDER
Increase
Decrease
New Bond Amount: _________________
TO be attached to and form a part of Surety Company Bond No. ________________________
written by _________________________________________________________ as SURETY, on behalf
of
___________________________________________
as
PRINCIPAL,
in
the
sum
of
_________________________________________________________ ($_______________) Dollars, in
favor of the COMMONWEALTH of VIRGINIA, DIRECTOR, DIVISION OF MINERAL MINING
as OBLIGEE executed on _________________, 20____.
WHEREAS, the OBLIGEE issued to the PRINCIPAL Permit Number ______________ dated
on __________________, pursuant to the application of the PRINCIPAL,
WHEREAS, said bond and rider shall cover any and all land affected or to be affected by the
mining operation under the above-mentioned permit and revisions and renewals since the date of the
issuance of the permit,
NOW,
therefore,
the
amount
of
the
bond
is
increased
decreased
by
__________________________________________ ($____________________) Dollars to a total sum of
_________________________________________ ($____________________) Dollars, to cover the
additional/reduced cost of reclaiming all affected lands.
It is further agreed that all other terms and conditions of this bond shall remain unchanged.
SIGNED AND SEALED THIS
DAY OF_________________, 20_______.
1
DMM-167
Rev. 07/16
DIVISION OF MINERAL MINING
900 NATURAL RESOURCES DRIVE, STE 400
CHARLOTTESVILLE, VA 22903
(434) 951-6310
Permit Number:
Bond:
SURETY BOND RIDER
Increase
Decrease
New Bond Amount: _________________
TO be attached to and form a part of Surety Company Bond No. ________________________
written by _________________________________________________________ as SURETY, on behalf
of
___________________________________________
as
PRINCIPAL,
in
the
sum
of
_________________________________________________________ ($_______________) Dollars, in
favor of the COMMONWEALTH of VIRGINIA, DIRECTOR, DIVISION OF MINERAL MINING
as OBLIGEE executed on _________________, 20____.
WHEREAS, the OBLIGEE issued to the PRINCIPAL Permit Number ______________ dated
on __________________, pursuant to the application of the PRINCIPAL,
WHEREAS, said bond and rider shall cover any and all land affected or to be affected by the
mining operation under the above-mentioned permit and revisions and renewals since the date of the
issuance of the permit,
NOW,
therefore,
the
amount
of
the
bond
is
increased
decreased
by
__________________________________________ ($____________________) Dollars to a total sum of
_________________________________________ ($____________________) Dollars, to cover the
additional/reduced cost of reclaiming all affected lands.
It is further agreed that all other terms and conditions of this bond shall remain unchanged.
SIGNED AND SEALED THIS
DAY OF_________________, 20_______.
1
DMM-167
Rev. 07/16
I.
BY COMPANY/PRINCIPAL:
(SEAL) By: __________________________
Company /Principal
Company/Principal Official
_________________________________
Date
Title
Subscribed and sworn/affirmed to before me by ____________________________________,
this
day of
, 20
, in the City/County of
____________________.
(SEAL)
Notary Public
My Commission expires _____________________________, 20____.
II. BY SURETY: Attach copy bearing seal of Power of Attorney or documentation supporting
Corporate Officer’s authority to issue surety bond
.
(SEAL) By: ___________________________
Surety Name
Attorney-in-Fact
________________________
______________________________
Date
Typed name
My Power of Attorney is recorded in the Clerk’s Office of the Circuit Court of
________________________, Virginia, in Deed Book _________________, Page ____________,
or Instrument __________________, and has not been revoked.
______________________________________
Attorney-in-Fact
AFFIDAVIT AND ACKNOWLEDGEMENT OF ATTORNEY-IN-FACT
2
DMM-167
Rev. 07/16
COMMONWEALTH OF VIRGINIA
(or, alternatively, Commonwealth or State of _____________________) CITY/COUNTY OF
____________________________________, to wit:
I, the undersigned notary public, do certify that __________________________ personally appeared
before me in the jurisdiction aforesaid and made oath that he is the attorney-in-fact of
________________________________________________________, the Surety, that he is duly
authorized to execute on its behalf the foregoing Bond pursuant to the Power of Attorney noted above,
and on behalf of said Surety, acknowledged the aforesaid Bond(s) as its act and deed.
Given under my hand this ____________ day of _________________________, 20____.
__________________________________(SEAL)
Notary Public
My Commission expires: _____________________________, 20____.
III. BY ISSUING AGENT:
1. Attach copy of Agency License and Assignment Card from
Bureau of Insurance.
2. Attach
verification of individual’s authority to sign on behalf
of Agency
Agency Issuing Surety Bond (provide the following information):
Agency name:
_________
______
Authorized agent:
______________________________
Agent address:
___________
_____________
Office telephone number:
________________________
IV. DIVISION APPROVAL:
ACCEPTED: ________________________________________ Date__________________
Division of Mineral Mining
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DMM-167
Rev. 07/16
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