h_____ signed, sealed and published the same as ______h_____ free and voluntary act and deed for the uses and purposes therein set forth. WITNESS my hand and seal, this _____________ day of _____________________, 19____ My commission expires _____________________________________________, 19____ _____________________________________________________ Notary Public. ___________________________________________________________________________ STATE OF ________________________} } SS. County of _______________________} ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ of the Count ______ of ___________________________________________ State of ______________________, being first duly sworn according to law, depose and say_______: That_____h_____ citizen___ of the United States over the age of twenty-one years; that _____ h_____ owner_____ by pre-emption, location and occupation of the foregoing tunnel site, the said tunnel being prosecuted for the development of lodes belonging to said affiant_______, also for the discovery of other lodes; affiant___ further say ______ that ____ h_______ ha___ expended in actual work and improvements on said tunnel not less than __________________________________________________________________ Dollars, and that said tunnel has already been run the distance of _________________ ___________ feet, and that it is bona fide ___ h______ intention to prosecute work on said tunnel, so located and described, with reasonable diligence for the purposes therein set forth. ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ SUBSCRIBED and sworn to before me this ________________________________ day of ____________________________, 19____ My commission expires ______________________________________________, 19___ ____________________________________________ Notary Public. _______________________________________ LOCATION CERTIFICATE OF TUNNEL AND TUNNEL SITE _______________________________________ Tunnel and Tunnel Site of _____________ _______________________________________ in _____________________________ Mining