OHIO DEPARTMENT OF NATURAL RESOURCES
DIVISION OF OIL & GAS RESOURCES MANAGEMENT
2045 MORSE RD., F-2, COLUMBUS, OH 43229-6693
Phone: (614) 265-6922 • Fax: (614) 265-6910
EXEMPT DOMESTIC WELL OWNER AFFIDAVIT
RELEASE OF LEASE(S)
Owner Number____________
(To be filled in by the Division)
STATE OF___________________________________
SS:
COUNTY OF_________________________________
NAME OF ASSIGNOR/TRANSFEROR:_____________________________________________________________________
Please print name and title
ADDRESS OF OWNER:_________________________________________________________________________________
I the undersigned, being first duly sworn, depose and state that upon execution of this affidavit and the attached Form 7, I/We
have, as the assignor/transferor, released all the oil and gas leases that are included in the applicable formation of the drilling
unit for the respective well listed on the Form 7. The release is in a form such that the well ownership merges with the fee simple
interest of the surface tract and the release is in a form that may be recorded.
I have attached a copy of the release.
Permit No. _________________, known as the ___________________________________well #_________, located in
_________________________Township ________________________, County, Ohio
Further affiant sayeth naught.
Signature(s)/Title: ___________________________________________________________________________________
SWORN to before me and subscribed in my presence this ________ Day of _____________________, 20_________.
NotaryPublic: __________________________________________________
(Seal)
_________________________________________________
Date Commission Expires
***This is to be included as an attachment to the Request for Change of Owner (Form 7)
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