Government of Ontario: Ministry of Northern Development and Mines

Dispute Against a Recorded Claim

Mining Act

Transaction Number (office only)

Personal information collected on this form is obtained under the authority of the Mining Act. This information will be used for serving notice. Questions about this collection should be directed to a Provincial Mining Recorder, Ministry of Northern Development and Mines, 3^rd Floor, 933 Ramsey Lake Road, Sudbury, Ontario, P3E 6B5. Phone number 1-888-415-9845 or (705) 670-5742. Fax No. 1-877-670-1444 or (705) 670-5681.

I, name (print or type)
allege that Mining Claim No.(s)

see attached schedule

in the Choose Appropriate Division Mining Division
recorded in the name of

is illegal or invalid in whole or in part because: (state generally how and why claim is illegal or invalid, with details to be set out in an attached Statement of Claim).

If the disputant, or the person on whose behalf the applicant is acting, claims to be entitled to any right or interest in the lands or mining rights, or any part thereof, comprised in the disputed claim, give a general statement of particulars below with details to be set out in an attached Statement of Claim.

Certificate Verifying Dispute

I, (print or type)

Certify:

I have personal knowledge of the matters mentioned in the annexed dispute and the statements contained in it are true.

Disputant’s Address for Service in Ontario

Disputant’s Telephone No.
( )

Fax Number
( )

Signature of Disputant

Date (yyyy/mm/dd)

"Mining Lands Website: http://www.mndm.gov.on.ca/mndm/mines/lands/default_e.asp"

0237E (04/2006)

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