Government of Ontario: Mining and Lands Commissioner

Application for Determination of Surface Rights Compensation

Under Subsection 79(3), Mining Act, R.S.O. 1990, c. M.14

Personal information collected on this form is obtained under the authority of the Mining Act, R.S.O. 1990 c. M. 14. This information will be used for correspondence. Questions about this collection should be addressed to the Mining and Lands Commissioner, P.O. Box 330, 24^th Floor, 700 Bay Street, Toronto, Ontario M5G 1Z6.

Applicant

Telephone ( )

Street No. Unit/Suite/Apt
Street Name
City/Town or Village
Province/State
Country
Postal Code/Zip Code

Applicant's Lawyer or agent (if any)

Telephone ( )

Street No. Unit/Suite/Apt
Street Name
City/Town or Village
Province/State
Country
Postal Code/Zip Code

Property to which application relates Mining Division
Lot/Concession/Township

Mining Claim No.

State briefly the reasons for the application

State the amount of compensation offered and the amount expected

Name of the Other Party

Telephone ( )

Street No. Unit/Suite/Apt
Street Name
City/Town or Village
Province/State
Country
Postal Code/Zip Code

Signature

Date (yyyy/mm/dd)

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

0253E (04/2006)

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