Form Sv 1 - Application For Severer'S License To Sever Natural Resources In Ohio
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SV 1
Rev. 4/08
P.O. Box 530
Columbus, OH 43216-0530
Application for Severer’s License
To Sever Natural Resources in Ohio
Pursuant to Ohio Revised Code Section 5749.04, the $50 fee for this license is waived if a permit, license, owner number, etc.,
is obtained from the Ohio Department of Natural Resources. Please complete the following if you are entitled to this exemption:
Department name
Type of license or permit
License or permit number
If such permit, license, owner number, etc., was not obtained, please enclose payment in the amount of $50 so that your
application can be processed.
Name
FEIN
DBA
Social Security number
Street
Telephone number
City
State
ZIP code
Fax number
When did or when will you start operating?
Month
Year
Locations in Ohio where severing activities occur – county, township, section, quarter and/or lot number
Check whether severer operates as:
Sole owner
Partnership
Fiduciary
Association
LLC
LLP
Corporation Corporate charter number
List below the titles, names and addresses of all corporate offi cers, association offi cers, or partners.
Title
Name
Address
Oil
Check resources to be severed:
Coal
Salt
Limestone
Dolomite
Sand
Gravel
Gas
Clay
Sandstone/Conglomerate
Shale
Gypsum
Quartzite
I hereby declare the above to be true and correct to the best of my knowledge and belief.
Date
Signature of severer or agent
All questions on this application are to be answered. This license, when acknowledged, shall continue valid until surrendered by
the severer or canceled for cause by the tax commissioner. THIS IS NOT AN ANNUAL LICENSE AND WILL NOT REQUIRE A
RENEWAL. Make $50 license fee payable to Ohio Treasurer of State and forward with severer’s application to Department of
Taxation, Excise Tax Section, P.O. Box 530, Columbus, OH 43216-0530.
If you have any questions, please call (855) 466-3921.
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