STATE OF COLORADO | ) |
) | ss. |
County of ..................................... | ) |
Before me, the subscriber personally appeared ............, who, being duly sworn, saith that at least ........ dollars [worth of work or improvements were performed or made upon] [claim rental fee as required by federal law was paid upon] (here describe claim or part of claim), situate in .............. mining district, county of .............., state of Colorado, between the .............. day of .............., A.D..., and the .... day of .............., A.D.... Such expenditure was made by or at the expense of .............., owners of said claim, for the purpose of complying with the law, and holding said claim.
Jurat:
(Signature) ......................................
C.R.S. § 34-43-114