Transfer of Mineral Claim

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Form 17

Protected A

Privacy Act Statement

The information you provide on this form is collected by Aboriginal Affairs and Northern Development Canada under the authority of the Northwest Territories and Nunavut Mining Regulations for the purpose of transferring of a mineral claim. The information may be made available for public inspection, as prescribed by the Regulations, and will be handled in accordance with the provisions of the Privacy Act  . Individuals have the right to the protection of unauthorized disclosure of and access to their personal information that is under the control of a federal government institution. Instructions for obtaining your personal information are provided in Info Source  , a copy of which is available at major public and academic libraries or on line.

For Office Use Only 
Registered and Recorded in the Office of the Mining Recorder at Yellowknife, NWT or at Iqaluit, Nunavut
Date (YYYY-MM-DD)

 
Document Number
Mining Recorder's Signature


 
 
Name of Transferor


Amount of Fees

$
Receipt No.


Interest in Mining District


Ο NWT


Ο Nunavut


Claim Tag No.
 

 

 


Claim Name
 

 

 


Claim Tag No.
 

 

 


Claim Name
 

 

 


If insufficient space attach a sheet which shall form part of this document.
 
 

I, the recorded holder of (indicate interest held) __________________________________ %,
in consideration of receipt of (dollars) $ _________________________________________
transfer (indicate interest transferred) __________________________________________ %
to (name of transferee) _____________________________________________________.

 

Prospector's License No. of Transferee (Valid Licence Required)
 


Address of Transferee
 

 
 

 
 


Witness

_____________________
Signature of Transferor

_____________________
Date (YYYY-MM-DD)

_____________________

Witness

_____________________
Signature of Transferor

_____________________
Date (YYYY-MM-DD)

_____________________


 

Corporate Seal


 
 
Note:
The second signature line is provided for corporations requiring two signing officers.
The signature(s) does(do) not need to be witnessed if a corporate seal is used.
 
 

Affidavit of Witness (Not required if Corporate Seal is used) 


CANADA TO WIT:

I _________________________________________________________________________

of the _____________________________________________________________________

in the _____________________________________________________________________

MAKE OATH AND SAY

THAT I was personally present and did see the within instrument duly signed, sealed and executed by one of the parties thereto.

At ________________________________ in the ________________________________

THAT I know the said ______________________________________________________

AND THAT I am a subscribing witness to the said instrument.

SWORN BEFORE ME this ______ (Day) of __________________ (Month), ________ (Year)

at ________________________________ in the ________________________________


Signature of Notary Public - Signature of Commissioner for Oaths
 


Signature of Witness
 


A Commissioner for Oaths / Notary Public in and for the
 


My Commission / Appointment Expires
(YYYY-MM-DD)
 


Signature of Witness
 


 
 

INTER 50-012E 2012-04-01