ROW OTHER AUTHORIZED WORK CLEANING STRIPPING

Conducted
=°ci~veIopment;- ,~~t;~r~Report of Work Conducted
j
Mihes
Number I,
I
11 l~ransaction
T~ansaction Number
' iina Claim
,"~t"iAfter Recotding
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Mining Ae
o;ij,~formISOb1alned~,"dertheauthoritYOfthE
mati ion cdHected on this form is obtalned under the authoritv of the
~.____
11
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)n should boa dlfected to the ,ProvInclal Manager. Mining Lands, t.
J~ntarlo;P3E 'BAS, telephone (705) 670-7264.
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submit In duplioate.
and submit in duplicate.
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52A10SW5003 W9104-05074 MACGREGOR
52A10SW5003 W9104-05074 MACGREGOR
010
. Refer'lathe Mining
ining Act and
and Regulations
Regulations for requirements
requirements of filing assefsment
assefisment work or consult the Mining
Mining
Recorder.
.
'
~,(separatecopy
ecopy of this form mUist
must be
be completed
completed for each
each Work Group.
Grpup.
mUl~t accompany
accompany this form
• - Technical reports
reports and
and maps
maps must
form in
in duplicate.
~·Asketctt., showing
showing the claims
thl9 work is assigned
form .
claims thcs
assigned to, must accompany this form.
. d-.L/8-
dress
. ".
.....
\l\t.:~:
Dates -
<;
\
.
k Ip
Y .
From:
Work
performed
From:
M0 \.)
IS\
II \ ~ \
&, .,
1 L·.:.L--
To:
I
lork
Performed (Check One Work
GeoteChnical
GeotechnicJ Survey
Physical Work,
fncIuding Drilling
Rehabilitation
Other Authorized
Work
Assays
from
Assignment from
Reserve
Reserve
-
-
$s
Jtal
Attached Statement
3tal Assessment Work Claimed
Claimed an
on the Attached
Statement ,of
of Costs
ote:
ote:
-
().()~
468*0&
--~~~~--------------------
The Minister
Minister may reject
reject for assessment work credit
credi't all
all or part of the assessment work submitted
submitted if the recorded
recorded
holder cannot verify expenditures
a request
of'a
request for verification.
expenditures claimed
claimed in
in the statement
statement of costs
costs within 30 days of
ersons and Survey Company Who Performed
Performed the Work (Give
(Give Name
Name and
and Address of Author of Report)
Report)
Name
Name
Address
-
Shu~.,q'~2p~k~d
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tUlCh a schedide If necessary)
)rtlflC8t1on
,rtMc&on of Beneflelallnterest
Benetlclal Interest .' *' See Note
Note No. 11 OJ!
on rl!verse
reverse side
I
certify
claims covered
cerUb that at the time the work was performed,
oerlormed. the claims
covered in
in this work
aport
were recorded
the current hoIder's
epofl k
tecorded in
in thecurrent
hokier's name
name or held
held under a beneficial
beneficial interest
interest
Jy the currenl
current recorded
~y
recorded holder.
Oate
1 Date
Recorded
Recorded Holder or Agent (Signature)
(Signature)
)JD(jo!h,<~
.
a d a t t o n ~'wo&depoit
have a personal
personal knowledge
knowledge 01
of the facts set folrth
in this Work report,
report, having
having performed
performed the work or witnessed
during and/or
andlor after
II cettify
certify that IIhave
fOlrth In
witnessed same during
its completion
compleHon and
erid annexed
annexed report
repart is true.
lame
Address o
of
Certifying
; a m and Addresa
f Person
Person Certityino
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62.22/74
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-elepone
.eleponsNo.
Date
Date
CertlfiAt!
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In
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Credits you
you are
are claiming
claiming in
in this
this report
report may
may be
be cut
cut back.
back. in
In order
order to
to minimize
minimize the
the adverse
adverse effects
effects of such
such deletions,
deletions, please
please indicate
indicate from
from
Credits
I which
which claims
claims you
you wish
wish to
to priorize
priorize the
the deletion
deletion of crt3dits.
credits. Please
Please mark
mark ((rc)
one of the
the following:
following:
..... ) one
1.
1.
0
Credits are
are to
to be
be cut
cut back
back starting
starting with
with the
the claim
claim
listed last, working
working backwards.
backwards.
Credits
listed
,
2.
0
0
Credits
Credits are
are to
to be
be cut
cut back
back equally
equally over all
all c:laims
claims contained
contained in
in this
this report
report of work.
work.
'
!
3.
3.
Credits are
are to
to be
be cut
cut back
back as
as priorized
priorized on
on the
the aU
an ched
ched I~ppendix.
appendix.
Credits
8
4-
In the
the event
event tMt
that you
you have
have not
not specified
specified your choicI3
choice of pp iority,
iority, IJp!tion
option one
one will
will be
be implemented.
implemented.
In
\~ote1:
'dote 1:
~ote
tote 2:
nsfem, option
option agreements, memorandum
memorandum of agreements, etc.,
etc., with
with respect
Examples
Examples of beneficial
beneficial Interest
Interest are
are unrecorded
unrecorded tr nsfers,
to
t o the mining
mining claims.
If work has
ed land, please
has been
been performed
performed on
on patented
patented Il)r
w lea
leabed
please complete
complete the following:
IPatente~
certify that
that the
the recorded
recorded holder had
had a beneficial
beneficial interest
interest i1
iI) the
the Ipatented
II cert,ify
L
or leased
'~.=
leased land
land at the
the time
time the
the work was performed.
performed.
Date
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/
Ministryof
of
Ministry
NorthernDevelopment
Development
Northern
Ontario and
and MilJes
Mines
Ontario
b*nist&e du
du
M';"iste~e
Bveloppem~ent
du Nord
Nord
~veloppem,emt
du
/
.
Statement of
of Costs
Costs
Statement
for Assessment
Assessment Credit
Credit
for
tat des
des coOts
collts aux
'aux fins
fins
Etat
du credit
credit d'evaluation
d'evaluation
du
des mines:
mines:
- tt des
Mining Act/Loi
AcULoi sur
sur les
les mines
mines
Mining
'ersonal information
informationcollected
collected on
on this
this form
form Is
is obtained
obtained under
under the
the authority
authority
'arsonal
the Mining
Mlnlng Act.
Act. This
This Information
Informationwill
wlll bEl
bg used
used to
to maintain
maintain aa record
record and
and
ff the
going status
statusof
of the
the mining
miningclaim(s).
claim(s). Questions
Questionsabout
about this
this collection
collectionshould
should
,going
directed to
to the
the Provincial
ProvlnclalManager,
Manager, Minings
MiningsLands,
Lands, Ministry
Ministryof
of Northern
Northern
j :directed
jevelopment and
and Mines,
Mines, 4th
4th Floor,
Floor. 159
159 Cedar
Cedar Street,
Street, Sudbury,
Sudbury, Onllario
Onltario
)evelopment
3E 6A5,
6A5, telephone
telephone (705)
(705) 670-7264.
670-7264.
3E
Les
contenus dans
dans la
la presente
ptdsente formule
formule sont
sont
Les renseigneri1ents
renseignements personnels
personnels contenus
recueillis
vertude
dela
laLol
Lolsur
surles
lesmines
mlneset
et servlront
serviront B (enir
tenir jour
jour un
unregistre
registre
recueillisen
envertu
rninibres. Adresser
Adresser to
toute
quesiton s\,lr
sbr la
la collece
collece de
de ces
ces
des concessions
concessions miniares.
des
ute quesiton
renseignements
miniers, ministere
rninistbre du
du
renseignements au
au chef
chef provincial
provincial des
des terrains
terrains miniers,
e etage,
Developpement
DBveloppement du
du Nord
Nordet
et des
des Mines,
Mines, 159,
159, rue
rue Cedar,
Cedar, 44e
Btage, Sudbury
Sudbury
(Ontario)
P3E 6A5,
6A5, telephone
tBl6phone (705)
(705) 670-7264.
670-7264.
(Ontario) P3E
a
.
Direct Costs/CoOts
CostslCoOts directs
dlrects
. Direct
Type
2.
2. Indirect
indirect Costs/CoOts
CostslCoGts indirects
indirects
Main-d'oeuvre
Note: When
When claiming
claiming Rehabilitation
Rehabilitation work
work Indirect
Indirect costs
costs are
are not
not
.... Note:
allowable
'
allowable as
as ass'essment
assessment work.
work.
Pour
Pour Ie
le remboursement
remboursementdes
des travaux
travaux de
de rehabilitation,
rdhdbilitation, les
les
coots
coOtsindirects
indirectsne
nesont
sont pas
pasadmissibles
admissibles en
entant
tant que
quetravaux
travaux
d'evaluation.
d'8valuation.
Field Supervision
Supervision sur Ie terrain
/
Amount
Montant
Description
Totals
Total global
Labour
Wages
Salalres
a
Type
Type
Transportation
Transport
Contractor'.
and Consultant's
Fees
~----------------~------~
Drolts de
I'entrepreneur
et de I'expertconsall
1
Description
1
Amount
Amount
Montant
Montant
1
Totals
Totals
Total
Total global
alobal
I
Type
SUpplies Uaed
Foumltures
utlll...s
Food and
Lodging
Nourrlture et
hebergement
Mobilization and
Demobilization
Mobilisation et
demoblllsation
Equipment
Rental
~ o c a t l o nde
de
I...ocatlon
mat6r1el
Sub Totll of Indirect Costs
Total partiel des coOts
c o Q t s indirects
Amount Allowable (not greater
than 20% of Direct
costS)
greeter than
Dlrect Costs)
Montant
Montant admissible
admissible (n'excedant
(n'exddant paS'
palr 20 %
% des coats
collts directs)
directs)
Total Value of Assessment
Assessment Credit
Credlt
Total
(Total
(Total of Direct
Dlrect and
end Allowable
Indirect
lndlrect costs)
costa)
Total Direct Costs
Total des coOts
coots directs
dlrects
.rte:
'te: The recorded
recorded holder will be required
required to verify expenditures claimed
claimed in
this statement of costs within 30 days of a request for verification. If
verification
verification is not made, the Minister may reject for assessment woirk
wo,rk
all or part of the assessment work submitted.
,I.
t-......-'"......o.t
Note:: Le titulaire
titulaire enregistre
enregistre sera tenu de verifier les dBpenses
depenses demandbs
demandees dans
Note
Ie present Btat
etat des coirts
couts dans les 30 jours suivant une demande h
a cet
le
Ie ministre peut rejeter tout
effel. Si la verification
verification n'est paseffectuee,
pas effectuee, le
effet.
d'evaluation prbsentes.
presentes.
ou une partie des travaux d'6valuation
Remises ppour
o u r dep6t
:lIlng
:::lIIng Discounts
.
Valeur totale du credit
Veleur
d'evaluation
d'bvaluation
(Total
coOtl dlrects
directs
(Total des coats
et
admlsslbles
et Indlrects
lndlrscts adrnlsslbles
Work filed within two years of completion is claimed at 1000/0
100% of
the above Total Value of Assessment Credit.
Credit.
1. Les travaux deposes dans les deux ans suivant leur
leur achdvement
achevement sont
Oro
susmentionnee du crMit
credit d'evaluation.
rem bourses Ba 100 o
rembourgs
h de la valeur totale susmentionnC
Work filed three,
three, four or five years after completion is claimed at
50%
50% of
of the above Total Value of
of Assessment
Assessment Credit. See
calculations below:
below:
apres leur achbvement
achevement
2. Les travaux deposes trois, quatre ou cinq ans aprbs
rembourses a
a 50 010
% de la valeur totale du credit d'dvaluation
d'svaluation
sont rernboursbs
susmentionne. Voir les calculs ci-dessous.
susrnentionn8.
r
7 Total
ed
Total Assessment
Assessment Clai
Clared
7rotal Value of Assessment Credit
xX 0.50 =
,
d'evaluation
Valeur totale du credit d16valuation
Attestation de i'btat
I'etat des coGts
couts
Attestation
:eftificetion
:ertificatlon Verifying
Verifying Statement of Costs
hereby
hereby certify:
certify:
la1
osts
lal the
the amounts
amounts shown
shown are
are as
as accurate
accurate as
as possible
possible and
and these
these fosts
,ere
n the
own
lere incurred
incurred while
while conducting
conducting assessment
assessment work
work oon
the lands
lands ssrown
)n
In the
the accompanyin
accompanyin Report
Report of
of Work
Work form.
form.
4:
iat as
-
F
--
(Recorded Holder, Agent. Position in Company)
3') make
make this
this certification
certification
I a m authorized
'
J'atteste par
par la
la presente
presente ::
J'atteste
que les
les montants
montants indiquhs
indiques sont
sont le
Ie plus
plus exact
exact possible
possible et
et que
que ces
ces
que
depenses
ont
ete
engagees
pour
effectuer
les
travaux
d'evaluation
dbpenses ont 6th engagbes pour effectuer les travaux d'evaluation
I sur
sur les
les terrains
terrains indiqubs
indiques dans
dans la
la forrnule
formule de
de rapport
rapport de
de travail
travail ci-joint.
ci-joint.
Et qu'h
qu' atitre
titre de
de
• je
je suis,
suis autorise
autorise
Et
(titulaire enregistrd,
enregistre. reprbsentant,
representant. poste
poste occupe
occupe dans
dans la
la, compagn~e)
compagnie)
(titulaire
faire cette
cette attestation.
attestation.
\d 82
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16.1 Aafaire
02
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Dans cette
celie formule,
formule, lorsqu'il
10rsqu'iI dBsigne
designe des
des personnes,
personnes, le
Ie rnasculin
mascuiin est
estutilisd
utilise au
au sens
sens neutre.
neutre.
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demandee
Evaluation totale dernandee
0,50 =
xx 0,50
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