AFFIDAVIT OF HEIRSHIP
Attached to and made a part of that certain Oil and Gas Lease dated March 13, 2009 by and
between Jerry B. Robertson, a/k/a Jerry Ben Robertson, a single person, as Lessor, and
___________Land, Inc., as Lessee, covering lands located in:
S/2 N/2 SW/4, SE/4 SW/4 less all that part of S/2 N/2 SW/4 lying North of Dwight Mission
Road in Section 26, Township 13 North, Range 23 East in __________County, ___________
BEFORE ME, the undersigned authority, on this day personally appeared Jerry Ben
Robertson, well known to me to be a credible person, who being by me sworn to tell the truth,
the whole truth, and nothing but the truth, made the following answers, swore these answers
were true, to the best of his/her knowledge and belief, and subscribed his/her name below:
1.
Affiant name and present address:
Jerry Ben Robertson
Route 2, Box 69
Vian, OK 74962
2.
I am acquainted with and/or have family history on:
Maymie Ketterman (decedent)
3.
How long did you know her/him?
4.
What was his/her date (and place) of birth?
5.
What was his/her date (and place) of death?
6.
Was decedent ever married? (If No, skip to #7)
Yes
No
How many times?
Name/Address
Date of
Date of
of spouse (or spouses)
Marriage
Death/Divorc
e
Did spouse leave a will?
Yes
No
Was their estate probated?
Yes
No
County and State and Number:
Did decedent divorce from any spouse?
Yes
No
If Yes, County, State and date:
7.
Did decedent leave any will within your knowledge?
Yes
No
(attach copy if available)
8.
Was there judicial determination of the estate?
Yes
No
If Yes, State, County, Number?
(attach copy if available)
9.
What are the names of all decedent=s children (including adopted and step-
children), their address, their birth dates and date of death, if applicable?
(If decedent had no children, go to #11)
Date of
Date of
Name/Address of Children
Birth
Death
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