Change Of Owner

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R E Q U E S T FOR C H A N G E OF O W N E R (Form 7)
OHIO DEPARTMENT OF NATURAL RESOURCES
Division of Oil and Gas Resources Management, 2045 Morse Road, Bldg. F-2, Columbus, OH 43229-6693
(614) 265-6922
A non-refundable fee of $100.00 per well must accompany this form. Make checks payable to the Division of Oil and Gas Resources Management.
Number of wells to be transferred
Amount enclosed
1. Date of Application:
2. Check Type of Request:
If Individual Transfer, indicate API number:
If Multiple Transfer, list all API numbers and complete date on back of form.
3. COUNTY:
12. Assignor Address and Telephone Number:
4. CIVIL TOWNSHIP:
5. WELL:
6. LEASE NAME:
13. Assignee/Transferee:
7. SECTION: __________________
8. LOT: _________________
14. Owner Number:
9. FRACTION:_________________
10. QTR TWP: ___________
11. I, We (Assignor/Transferor)
15. Assignee Address & Telephone Number:
hereby requests that
Owner #
hereby request that
records on file with the Division of Mineral Resources Management, ODNR,
State of Ohio, be amended to reflect the change of owner of the oil and/or
16. Exempt Domestic Well (see criteria for domestic wells on
gas well described in 3 through 10.
attached information sheet)
IF WELL HAS NOT BEEN SPUDDED, IT CANNOT BE TRANSFERRED
)
No
Yes
( # acres
The spacing/acreage requirements in effect under Ohio law at the time the well(s) was drilled will remain in effect for as long the well(s) exists.
A revised survey plat and appropriate fee must be submitted to the Division if any changes are made to the drilling unit on file at the Division.
ASSIGNOR/TRANSFEROR:
I, the undersigned, hereby agree to furnish any and all records and reports required by the Division of Oil and Gas Resources Management
for compliance with Chapter 1509., ORC, and all rules of that Division for the period ending on the date of assignment. Furthermore, I hereby
depose and state that all holders of royalty interests that are affected by this assignment or transfer will be properly notified in conformance with
Section 1509.31, ORC. It is understood that my liabilities for this well WILL NOT BE TERMINATED UNTIL I COMPLY WITH THE ABOVE.
_______________________________________________________________________________________________________________
(Signature of Assignor/Transferor)
ASSIGNOR/TRANSFEROR:
(Printed or Typed)
STATE OF ____________, COUNTY OF _____________________, being first duly sworn by me, says that the information set forth herein is
true and accurate. SWORN TO AND SUBSCRIBED BEFORE ME THIS ________ day of ______________________, 20_____.
_______________________________________________________________________________
(SEAL)
(Notary Public)
My Commission Expires
NOTE FOR WELLS TRANSFERRED TO LANDOWNERS: The well you are purchasing for domestic use may require periodic servicing to
maintain productivity. When the well becomes incapable of production, you are required to plug the well and restore the site in accordance
with Division requirements. Any brine produced must be properly disposed in accordance with Chapter 1509., ORC. You should be aware
after transfer, ALL EXPENSES incurred are the responsibility of the well owner.
ASSIGNEE/TRANSFEREE:
I, the undersigned, depose and state that I am the owner of aforementioned oil and/or gas well and that I have the right to appropriate the
oil or gas that I produce therefrom either for myself or others. I further depose and state that I shall comply with the assignor/transferor's Resto-
ration Plan and will comply with the requirements of Chapter 1509., ORC, and Chapter 1501., OAC, for the disposal of brine. Further, it is
understood that upon proper completion of this form, I will become the "owner" as defined under Chapter 1509., ORC, and must comply
with all laws, rules and orders by the Chief of the Division of Oil and Gas Resources Management.
_______________________________________________________________________________________________________________
(Signature of Assignee/Transferee)
ASSIGNEE/TRANSFEREE:
(Printed or Typed)
STATE OF ____________, COUNTY OF _____________________, being first duly sworn by me, says that the information set forth herein is
true and accurate. SWORN TO AND SUBSCRIBED BEFORE ME THIS ________ day of ______________________, 20_____.
_________________________________________________________________________________
(SEAL)
(Notary Public)
My Commission Expires
DIVISION USE ONLY
Certificate of Insurance
Date transferred ____________
Authority & Organization Form
Transfer Fee ____________ Check # ____________
Initials ____________
DNR 5616 (Rev. 04/2012)
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