Clear Form
Proof of Confirmation of
Staking Mining Claim(s) to
Surface Rights Owner
Ministry of
Northern Development
and Mines
Personal information collected on this form, if any, is collected under the authority of section 46.1 and subsection 178.2(1) of the Mining
Act and is necessary to the proper administration of a lawfully authorized activity. This information will be used for the purposes of
administering mining claims and ensuring compliance with the requirements of the Mining Act. Questions about this collection should be
directed to a Provincial Mining Recorder, Ministry of Northern Development and Mines, 3rd Floor, 933 Ramsey Lake Road, Sudbury ON
P3E 6B5. Telephone: 1 888 415-9845; Fax No.: 1 877 670-1444.
(Complete this part and file at the Provincial Recording Office.)
I,
Full Name of Licensee
client number
located at
Street, No., Unit
City, Town, Village
Business Telephone
Province or State
Fax
Email (Optional)
confirm that I gave confirmation of staking for the listed mining claim(s) to the corresponding surface rights owner(s) as set out below, at
their last known address:
Claim Number
Name of Surface Rights Owner
Signature of Licensee
Date Confirmation was Sent
(yyyy/mm/dd)
Date (yyyy/mm/dd)
It is an offence under the Mining Act to knowingly make a false statement on this form.
Office Use Only
Received Stamp (Office Use Only)
Print Form
0301E (2013/03)
© Queen's Printer for Ontario, 2013
Disponible en français