Affidavit For The Cancellation Of An Entire Water Right Certificate Form - Oregon
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1AFFIDAVIT FOR THE CANCELLATION OF AN ENTIRE
WATER RIGHT CERTIFICATE
State of Oregon
)
) ss
County of ____________________________
)
I/We (or authorized agent), _____________________________________________________________,
residing at ___________________________________________________________________________,
telephone number _____________________________________, being first duly sworn depose and say:
1. I/We are the legal and deeded owner(s) of the property described as tax lot number _____________,
within the ______¼ ______¼, Section ______, Township ____ N/S, Range ____ E/W, of the
Willamette Meridian, in __________________________________ County, Oregon, as shown on the
attached map and described in the attached deed and legal description and made part of this affidavit;
2. Water right certificate number _____________ issued to ___________________________________,
with a date of priority of ____________________ for use of ________ cubic foot per second of water
from _______________________________________________________________ (source) for the
purpose of __________________________________________________________ (use) is
appurtenant to my/our property;
3. The appurtenant water right is/is not located within the boundaries of an irrigation, drainage, water
improvement, or water control district, or federal reclamation project (if the right is located within a
district or reclamation project, name it here: ___________________________________________);
and
4. I/We have abandoned any and all interest in this water right and request the right be canceled.
___________________________________
_______________________
Signature of legal owner as listed on deed, or authorized agent
Date
___________________________________
_______________________
Signature of legal co-owner as listed on deed
Date
(If applicable)
Subscribed and Sworn to Before Me this _______ day of _____________________, 200___.
____________________________________
Notary Public for Oregon
My Commission Expires ___________________
PLEASE ATTACH A LEGIBLE COPY OF: 1) A DEED WHICH LISTS LAND OWNERS AND INCLUDES A LEGAL
DESCRIPTION OF AFFECTED LANDS, AND 2) A COPY OF AN ADJUDICATION MAP, WATER RIGHT FINAL PROOF
MAP, OR A TAX LOT MAP WITH THE ABANDONED RIGHT CLEARLY DRAWN AND IDENTIFIED. IF ACTING AS
AN AUTHORIZED AGENT, INCLUDE COPY OF POWER OF ATTORNEY OR OTHER DOCUMENTS GRANTING
AUTHORITY TO ACT ON BEHALF OF LEGAL OWNER(S).
December 2004 FSD
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