Form Dor Form 82063 - Property Tax Form - Oil, Gas And Geothermal Interests Page 4

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CONFIDENTIAL
VERIFICATION
State of ______________________
County of _____________________
I, ________________________________, being duly sworn, upon my oath say that I
am the __________________________ of _______________________________and
that the information contained in this report is complete, true and correct, according to the
best of my knowledge and belief.
________________________________
Signature
Subscribed in my presence and sworn to before me, a Notary Public, in and for said
County and State, by _________________________ on this the ________day of
______________, a. d. _______
My commission expires _________________________,
_________
In Witness Whereof, I have hereunto set my seal of office.
________________________________
Signature
DOR Form 82063 (Revised 11-12)
Page 4 of 4

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