Within the Meaning of the Act Respecting Access to Documents Held by Public Bodies And

Within the meaning of the Act respecting access to documents held by public bodies and the protection of personal information, the information identifying you is confidential. However, this information is essential for the processing of your file. Thus, the Department commits itself to restrict access to duly authorized people and to use and dispose of the confidential information in compliance with this Act.

Please inscribe the contact information of the person completing this form. The correspondence pertaining to the work report shall be sent and used for any additional information request.

Name / First name / Client number
Address / City
Province / Country / Postal code / Phone / Ext.
Fax / E-mail address

Please identify the operators as specified in the article 1 of the Mining tax act, c. I-0.4 and their percentage partnership for all the titles and work declared.

Name / Client number
Address / City
Province / Country / Postal code / Phone / Ext.
Fax / E-mail address
Quebec enterprise number (NEQ) / Percentage partnership

Please name the properties / projects associated with this declaration.

Name

As a mining right holder or his representative, you are responsible for all the information disclosed in this form. Select the appropriate box,

write your name in block letters, the date and sign the statement.

Statement of the mining right holder or his representative

I hereby certify that all information provided in this form, its annexes and attached documents is accurate, complete and submitted once only. I acknowledge to be the holder of this or these mineral rights or his duly authorized representative.

Name / First name
Date : / / / Signature :
Year month Day

Do not forget to attach the maps, plans, reports and registers required by regulation.

This form must be sent by mail only at the following address:
Ministère des Ressources naturelles
Service de la gestion des droits miniers
5700, 4e Avenue Ouest, local C-320
Québec (Québec) G1H6R1
RESERVED TO THE MINISTÈRE
No de requête: Date de réception: Initiales:

Ministère de l’Énergie et des Ressources naturelles Service de la gestion des droits miniers 2016-12-16 – Page 2 de 3

First, write the location of titles on the upper line and select the appropriate boxes. Then for each titles aimed in this statement, report here all the amounts declared in each annexes concerned and according to the nature of work performed. To do so, enter in the first column the title n° number, in the second column the number of corresponding hectares and, in the following columns, the amount reported according to the nature of work performed. Moreover, write at the end of each column and each line the total of costs as well as the great total.

Location : Township Seigniory N.T.S.leaflet

GP / GE / GC / FO / EP / DE / AN / EV / AU
Mining title n° / Nbre of
Hectares / Geophysical surveys / Geological surveys / Geochimical surveys / Boring (drilling) / Property examination / Stripping/Excavating / Sampling / Technical assessement / Other / TOTAL
1 / 1
2 / 2
3 / 3
4 / 4
5 / 5
6 / 6
7 / 7
8 / 8
9 / 9
10 / 10
11 / 11
12 / 12
13 / 13
14 / 14
15 / 15
16 / 16
17 / 17
18 / 18
19 / 19
20 / 20
21 / 21
22 / 22
23 / 23
24 / 24
25 / 25
26 / 26
27 / 27
28 / 28
29 / 29
30 / 30
31 / 31
32 / 32
33 / 33
34 / 34
35 / 35
TOTAL AMOUNT
GREAT TOTAL

Note : If the space is insufficient, print another page

Ministère de l’Énergie et des Ressources naturelles Service de la gestion des droits miniers 2016-12-16 – Page 2 de 3

Describe briefly the type of lines (indicated, cut, staked, etc). Write the period (year, month, day) during which cutting was carried out, the number of kilometers covered and the spacing between the lines. Enter in the last column the corresponding cost. Then add all the expenses and enter the total amount in box entitled TOTAL (1). Where applicable, distribute this amount between the various surveys in the space reserved for this purpose in sections 2, 3 and 4.

Nature of cutting / Date(s) of performance
from (year/month/day) to (year/month/day) / Length
in (km) / Spacing between lines / Cost
$
+
+
+
+
+
+
+
+
+
+
TOTAL (1) / =

Describe the method used, the period (year, month, day) during which surveys were carried out, the number of kilometers covered, the spacing between reading points, the number of readings and finally, in the column entitled COST, expenses incurred for each surveys. Where applicable, enter the attributable amount to line cutting. Add the entered amounts and inscribe in box entitled TOTAL (2) the total sum of costs disbursed.

This total must be deferred to section entitled "Identification and work synthesis" and distributed, by title, according to the nature of work.

Method used / Date(s) of performance
from (year/month/day) to (year/month/day) / Length
in (km) / Spacing between reading points
(in meters) / Cost
$
Interval / Number
+
+
+
+
+
+
+
+
+
Montant attribuable pour la coupe de lignes / +
TOTAL (2) / =

Describe the method used , the period (year, month, day) during which surveys were carried out, the number of kilometers covered, the interval between traversings and finaly, in the column entitled COST, enter the expenses incurred for each surveys. Where applicable, enter the ascribable amount to line cutting. Add the entered amounts and inscribe in box entitled TOTAL (3) the total sum of costs disbursed

This total must be deferred to section 3 in the zone entitled "Identification and work synthesis" and distributed, by title, according to the nature of work.

Method used / Date(s) of performance
from (year/month/day) to (year/month/day) / Surface
(in km2) / Interval between the traversings
(in metrers) / Cost
$
+
+
+
+
+
+
+
+
+
Montant attribuable pour la coupe de lignes / +
TOTAL (3) / =

Ministère de l’Énergie et des Ressources naturelles Service de la gestion des droits miniers Annexe 1 – 2016-12-16 – Page 1 de 2

Describe the method used , the period (year, month, day) during which surveys were carried out, the number of kilometers covered , the interval between sampling points, the number of samples and finaly, in the column entitled COST, enter the expenses incurred for each surveys. Where applicable, enter the attributable amount to line cutting. Add the entered amounts and inscribe in box entitled TOTAL (4) the total sum of costs disbursed.

This total must be deferred to section 3 in the zone entitled "Identification and work synthesis" and distributed, by title, according to the nature of work.

Method used / Date(s) of performance
from (year/month/day) to (year/month/day) / Length
(in km) / Interval between samples
(in metrers) / Cost
$
Interval / Number
+
+
+
+
+
+
+
+
+
Amount attributable to line cutting / +
TOTAL (4) / =

Detail here the various expenses incurred for line cutting and surveys by describing, for example, the costs incurred for wages, housing, supplying, transportation, instruments rental, analyses, drawings, etc. Moreover, indicate for each ones the corresponding cost. Add all the entered amounts and inscribe the total in box entitled Total (5).

Description / Cost
$
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
Caution, the total of this box must correspond to the total amount of previous TOTALS 2, 3 et 4. TOTAL (5) / =

Ministère de l’Énergie et des Ressources naturelles Service de la gestion des droits miniers Annexe 1 – 2016-12-16 – Page 2 de 2

List the name and address of the contractor in charge of carrying out the work program or the name and address of the personnel who participated in the work as well as the period (year, month, day) during which the work has been carried out . In the last column, inscribe the amounts disbursed for wages to the personnel or the cost disbursed to the contractor for the carrying out of work. Finally, add each costs and enter the total amount disbursed in box entitled TOTAL (1)

Identification
Name Address / Date(s) of performance
from (year/month/jday) to (year/month/day) / Wages or cost
$
+
+
+
+
+
+
+
TOTAL (1) / =

Detail briefly the type of transportation, housing and supplying. Inscribe the costs incurred for each one such as expenses for truck or vehicle rental, accomodation, restaurant or grocery shopping, etc.

Moreover, write for each means of transport the distance covered, in kilometers (km) from starting point to arrival point on the site, the number of people transported as well as the number of days of travelling . Then add each costs and enter the total amount disbursed in the box entitled TOTAL (2).

Description / Distance
(in km) / Nbre of people / Nbre of days / Cost
$
+
+
+
+
+
+
+
TOTAL (2) / =

Write the name of the laboratorie(s) who performed the samples analyses, the elements determined, the number of samples analyzed as well as the cost for each analysis. Add all the costs reported and enter the total amount in the box entitled TOTAL (3).

Name of laboratory / Elements determined / Nbre of samples / Cost
$
+
+
+
+
+
+
+
TOTAL (3) / =
Use this section to declare any other type of expenses incurred for drilling. Briefly describe the nature of expenses and enter the corresponding cost. Add each cost and enter the total amount in box entitled TOTAL (4)
Description / Cost
$
+
+
+
+
+
TOTAL (4) / =

Enter the total amount of expenses for boring work (drilling). This great total must be deferred to section 3 entitled "Identification and work synthesis" and distributed by title according to the nature of work.

GREAT TOTAL (1 + 2 + 3 + 4) =

In the following columns, list the number of titles and drill-holes on the land subject to the mining right as well as the overall length of the drill-holes in meters. Lastly, write the total number of meters of land drilled for all the titles in the box entitled OVERALL LENGTH OF DRILL-HOLES.

Mining title n° / Drill-holes n°on this title / Total lenght of drill-holes on this title
(in meters)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
TOTAL LENGTH OF DRILL-HOLES (IN METERS)

Ministère de l’Énergie et des Ressources naturelles Service de la gestion des droits miniers Annexe 2 – 2016-12-16 – Page 2 de 2

Identification
Name Address / Date(s)of performance
from (year/month/jday) to (year/month/day) / Wages or cost
$
+
+
+
+
+
+
+
+
TOTAL (1) / =

Description / Distance
(in km) / Nbre of people / Nbre of days / Cost
$
+
+
+
+
+
+
+
+
TOTAL (2) / =
Use this section to report any other type of expenses incurred in property examination. Briefly describe the nature of expenses and enter the corresponding cost. Finally, add each cost and enter the total amount in the box entitled TOTAL (3)
Description / Cost
$
+
+
+
+
+
+
+
+
+
TOTAL (3) / =

Enter the total amount of expenses incurred in property examination.

This great total must be deferred to section 3 entitled "Identification and work synthesis" and distributed, by title, according to the nature of work.

GREAT TOTAL (1 + 2 + 3) =

Ministère de l’Énergie et des Ressources naturelles Service de la gestion des droits miniers Annexe 2 – 2016-12-16 – Page 2 de 2