List the name and address of the contractor in charge of carrying out the work program or the name and address of the personnel who participated in the work as well as the period (year, month, day) during which the work has been carried out . In the last column, inscribe the amounts disbursed for wages to the personnel or the cost disbursed to the contractor for the carrying out of work. Finally, add each costs and enter the total amount disbursed in box entitled TOTAL (1) Identification Date(s) of performance Wages or cost Name Address from (year/month/jday) to (year/month/day) $ + + + + + + + TOTAL (1) = Detail briefly the type of transportation, housing and supplying. Inscribe the costs incurred for each one such as expenses for truck or vehicle rental, accomodation, restaurant or grocery shopping, etc. Moreover, write for each means of transport the distance covered, in kilometers (km) from starting point to arrival point on the site, the number of people transported as well as the number of days of travelling . Then add each costs and enter the total amount disbursed in the box entitled TOTAL (2). Distance Nbre of Nbre of Cost Description (in km) people days $ + + + + + + + TOTAL (2) = Write the name of the laboratorie(s) who performed the samples analyses, the elements determined, the number of samples analyzed as well as the cost for each analysis. Add all the costs reported and enter the total amount in the box entitled TOTAL (3). Nbre of Cost Name of laboratory Elements determined samples $ + + + + + + + TOTAL (3) = Use this section to declare any other type of expenses incurred for drilling. Briefly describe the nature of expenses and enter the corresponding cost. Add each cost and enter the total amount in box entitled TOTAL (4) Cost Description $ + + + + + TOTAL (4) =
List the name and address of the contractor in charge of carrying out the work program or the name and address of the personnel who participated in the work as well as the period (year, month, day) during which the work has been carried out . In the last column, inscribe the amounts disbursed for wages to the personnel or the cost disbursed to the contractor for the carrying out of work. Finally, add each costs and enter the total amount disbursed in box entitled TOTAL (1) Identification Name Address Date(s) of performance from (year/month/jday) to (year/month/day) Wages or cost $ + + + + + + + TOTAL (1) = Detail briefly the type of transportation, housing and supplying. Inscribe the costs incurred for each one such as expenses for truck or vehicle rental, accomodation, restaurant or grocery shopping, etc. Moreover, write for each means of transport the distance covered, in kilometers (km) from starting point to arrival point on the site, the number of people transported as well as the number of days of travelling . Then add each costs and enter the total amount disbursed in the box entitled TOTAL (2). Description Distance (in km) Nbre of people Nbre of days Cost $ + + + + + + + TOTAL (2) = Write the name of the laboratorie(s) who performed the samples analyses, the elements determined, the number of samples analyzed as well as the cost for each analysis. Add all the costs reported and enter the total amount in the box entitled TOTAL (3). Name of laboratory Elements determined Nbre of samples Cost $ + + + + + + + TOTAL (3) = Use this section to declare any other type of expenses incurred for drilling. Briefly describe the nature of expenses and enter the corresponding cost. Add each cost and enter the total amount in box entitled TOTAL (4) Description Cost $ + + + + + TOTAL (4) =
form-mines-work-declaration.docx