Affidavit Of Compliance Form - Louisiana
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1AFFIDAVIT OF COMPLIANCE
STATEWIDE ORDER 29-B
RULE LAC 43:XIX.103
WELL NAME AND NUMBER ___________________________
STATE OF _______________
PARISH/COUNTY OF ______________
BEFORE ME, the undersigned Notary Public, personally appeared _______________________,
(“affiant”) who on his oath did say that he is the ____________________ (REPRESENTATIVE) of the
____________________ (COMPANY), authorized to do business in the state of Louisiana, and that said
instrument was signed on behalf of said company, and affiant acknowledged that he executed the same as
the free act and deed of said company.
BY CHECKING THIS BOX, AFFIANT CERTIFIES:
The above referenced well will be
Surface owner was provided pre-entry
drilled from an existing pad on the
notice on the ______ day of _________,
property in question, there will be no
20________. No construction operations
expansion to the existing drilling pad or
of
a
drilling
location
for
the
access road(s) and therefore no notice to
aforementioned well shall commence
the surface owner is required pursuant to
less than thirty (30) days after such date.
R.S. 30:28(I)(1)(f).
A contractual relationship presently
exists between the operator and the
No pre-entry notice required pursuant to
surface owner(s) of the subject well. As
R.S.
30:28(I)(1)(d).
Please
attach
such, no pre-entry notice is required
documentation
of
Commissioner’s
pursuant to 30:28(I)(1)(c).
waiver.
The information in this affidavit meets the requirements of Statewide Order 29-B, Rule LAC 43:XIX.103
and Louisiana R.S. 30:28(I), demonstrating compliance with such order. By signing this document, I
certify that the foregoing is true and correct to the best of my knowledge.
Thus done and sworn this ________day of __________, 20___:
Signature:
__________________________
Print Name:
__________________________
Title:
__________________________
_____________________
Notary Public
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