Attachment 5: AML Contractor Information Form

OMB # 1029-0119
Expiration Date:
09/30/2027

ABANDONEDMINELANDS (AML)CONTRACTOR INFORMATIONFORM

You must complete this form for your AML contracting officer to request an eligibility evaluation from the Office of Surface Mining Reclamation and Enforcement (OSMRE) to determine if you are eligible to receive an AML contract. This requirement can be found under OSMRE’s regulations at 30 CFR 874.16. NOTE: This form must be signed and dated within 30 days of submission to be considered for a current bid. Part A: General Information
Business Name:

Tax ID #:

Address:
City, State, & Zip:
Phone Number:
Email Address:
Part B: Obtain an Organizational Family Tree (OFT) from the Applicant Violator System (AVS) If you plan to certify the existing AVS information or submit updates under Part C, you must include an OFT. Instructions for downloading an OFT from the AVS can be found at: https://www.osmre.gov/sites/default/ files/2022-02/OMB%201029-0119%20instructions.pdf. If you require assistance you may contact the AVS Office by phone at: 800-643-9748, or by email at: [email protected]. Part C: Certifying and updating information in the AVS
Select one of the options, follow the instructions for the selected option, sign, and date below.

I,

, have express authority to certify that:

(Print Name)

1. Our business is listed in the AVS. The information is accurate, complete, and up to date. (If you select

□ this option, you must attach an Entity OFT from the AVS to this form). Do not complete Part D. 2. Our business is in the AVS. The information needs to be updated. (If you select this option, you must an Entity OFT from the AVS to this form). Complete Part D to provide the missing or □ attach
corrected information.

is not listed in the AVS. The information needs to be added. Complete Part D to provide □ 3. Ourthebusiness
information.

Date

Signature

Title

OMB # 1029-0119
Expiration Date:
09/30/2025

Part D: OFT Information
Contractor’s Business Name:

If the current Entity OFT information for your business is incomplete in the AVS, or if there is no information in the AVS for your business, you must provide all of the following information as it applies to your business. Please include additional copies of this page if the space below is not sufficient to capture all information. • Every officer (President, VicePresident, Secretary, Treasurer,etc.); • AllDirectors, Partners, and Members;
• All persons performing a function similar to a Director; • Every person or business that owns 10% or more of the voting stock in your business;