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COUNTY OF ______________________|

Know All Men by These Presents, That ______________, the undersigned, ha____

this___________ day of________________, 19___, located and claimed, and by

these presents do _____locate and claim by right of discovery and location,

in compliance with the Mining Acts of Congress, approved May 10, 1872, and

all subsequent Acts, and with local customs, laws and regulations,

____________________ linear feet and horizontal measurement on the

____________________________________________ lode, vein, ledge or deposit,

along the vein thereof, with all its dips, angles and variations as allowed