Mineral Development & Lands Branch
Personal information collected on this form is obtained under the authority of subsection 189 (1.1) and 178.2(1) of the Mining Act. This information will be used for the purposes of processing the application and to communicate with the Registered Owner(s) and/or the named Contact Person in that regard. Questions about this collection should be directed to the Provincial Tax Coordinator, Ministry of Northern Development, Mines and Forestry, 933 Ramsey Lake Road, Sudbury ON P3E6B5. Telephone 1 888 415-9845. For more information on Mining Land Tax exemption, please visit the Ministry’s website: (Mines & Minerals Division – Mineral Development & Lands Branch – Mining Lands Section – Policies). Or, call the Dispositions Office 705 670-5847 / toll free at 1 888 415-9845 ext. 5847.
Last Name First Name
Unit No. Street No. Street Name Rural Route PO Box City/Town Province Postal Code
Applicant Telephone No. Applicant Mining land tax Account No. Applicant Sub-account No.
Are you aware of any mine hazards or other rehabilitation concerns relating to the land? Yes No
If yes please describe:
I/We, the registered owner(s) of the property(s) in question, here by my/our signature certify that:
Full Name of Registered Owner Signature Date (yyyy/mm/dd)
If the owner is a Corporation, print the signing officer’s name and position.
Position I have authority to bind the corporation.
Applicant Signature Date (yyyy/mm/dd)
It is an offence under the Mining Act to knowingly make a false statement on this form.
Office use only