43 C.F.R. § 2627.3
(a) Statutory authority.
(b) Lands subject to selection; patents; minerals.
(c) Applications for selection.
(1) Applications for selection of lands under the act will be made by the proper selecting agent of the State and will be filed, in duplicate, in the proper office of the district in which such selected lands are situated. No special form is required but it must be typewritten and must contain the following information:
(ii) A certificate by the selecting agent showing:
(a) That the selection is made under and pursuant to the laws of the State.
(b) The acreage selected and the cumulative acreage of all prior selection lists pending and finally approved for clear-listing or patenting.
(c) His official title and his authority to make the selection on behalf of the State.
(d) That no portion of the selected land is occupied for any purpose by the United States and that to the best of his knowledge and belief the land is unoccupied, unimproved, and unappropriated by any person claiming the land other than the applicant, and that at the date of the application no part of the land claimed or occupied under the mining laws.
(e) That the selected land does not extend more than 160 rods along the shore of any navigable water or that such restriction has been waived or should be waived. (§ 2094.2 of this chapter.)
(f) All the facts relative to medicinal or hot springs or other waters upon the selected lands.