R E Q U E S T FOR C H A N G E OF O W N E R (Form 7) OHIO DEPARTMENT OF NATURAL RESOURCES Division of Oil and Gas Resources Management, 2045 Morse Road, Bldg. F-2, Columbus, OH 43229-6693 (614) 265-6922 A non-refundable fee of $100.00 per well must accompany this form. Make checks payable to the Division of Oil and Gas Resources Management. Number of wells to be transferred 1. Date of Application: 2. Check Type of Request: If Individual Transfer, indicate API number: If Multiple Transfer, list all API numbers and complete date on back of form. 3. COUNTY: 4. CIVIL TOWNSHIP: 5. WELL: 6. LEASE NAME: 7. SECTION: __________________ 9. FRACTION:_________________ 11. I, We (Assignor/Transferor) hereby requests that Owner # hereby request that records on file with the Division of Mineral Resources Management, ODNR, State of Ohio, be amended to reflect the change of owner of the oil and/or gas well described in 3 through 10. IF WELL HAS NOT BEEN SPUDDED, IT CANNOT BE TRANSFERRED 8. LOT: _________________ 10. QTR TWP: ___________ 14. Owner Number: 15. Assignee Address & Telephone Number: 13. Assignee/Transferee: 12. Assignor Address and Telephone Number: Amount enclosed 16. Exempt Domestic Well (see criteria for domestic wells on attached information sheet) ) No Yes ( # acres The spacing/acreage requirements in effect under Ohio law at the time the well(s) was drilled will remain in effect for as long the well(s) exists. A revised survey plat and appropriate fee must be submitted to the Division if any changes are made to the drilling unit on file at the Division. ASSIGNOR/TRANSFEROR: I, the undersigned, hereby agree to furnish any and all records and reports required by the Division of Oil and Gas Resources Management for compliance with Chapter 1509., ORC, and all rules of that Division for the period ending on the date of assignment. Furthermore, I hereby depose and state that all holders of royalty interests that are affected by this assignment or transfer will be properly notified in conformance with Section 1509.31, ORC. It is understood that my liabilities for this well WILL NOT BE TERMINATED UNTIL I COMPLY WITH THE ABOVE. _______________________________________________________________________________________________________________ (Signature of Assignor/Transferor) ASSIGNOR/TRANSFEROR: (Printed or Typed) STATE OF ____________, COUNTY OF _____________________, being first duly sworn by me, says that the information set forth herein is true and accurate. SWORN TO AND SUBSCRIBED BEFORE ME THIS ________ day of ______________________, 20_____. (SEAL) _______________________________________________________________________________ (Notary Public) My Commission Expires NOTE FOR WELLS TRANSFERRED TO LANDOWNERS: The well you are purchasing for domestic use may require periodic servicing to maintain productivity. When the well becomes incapable of production, you are required to plug the well and restore the site in accordance with Division requirements. Any brine produced must be properly disposed in accordance with Chapter 1509., ORC. You should be aware after transfer, ALL EXPENSES incurred are the responsibility of the well owner. ASSIGNEE/TRANSFEREE: I, the undersigned, depose and state that I am the owner of aforementioned oil and/or gas well and that I have the right to appropriate the oil or gas that I produce therefrom either for myself or others. I further depose and state that I shall comply with the assignor/transferor's Restoration Plan and will comply with the requirements of Chapter 1509., ORC, and Chapter 1501., OAC, for the disposal of brine. Further, it is understood that upon proper completion of this form, I will become the "owner" as defined under Chapter 1509., ORC, and must comply with all laws, rules and orders by the Chief of the Division of Oil and Gas Resources Management. _______________________________________________________________________________________________________________ (Signature of Assignee/Transferee) ASSIGNEE/TRANSFEREE: (Printed or Typed) STATE OF ____________, COUNTY OF _____________________, being first duly sworn by me, says that the information set forth herein is true and accurate. SWORN TO AND SUBSCRIBED BEFORE ME THIS ________ day of ______________________, 20_____. (SEAL) DIVISION USE ONLY Certificate of Insurance Authority & Organization Form Transfer Fee ____________ Check # ____________ DNR 5616 (Rev. 04/2012) Page 1 of 2 _________________________________________________________________________________ (Notary Public) My Commission Expires Date transferred ____________ Initials ____________ American LegalNet, Inc. www.FormsWorkFlow.com Indicate under the status column whether the wells listed are producing or non-producing. STATUS PROD. API COUNTY TOWNSHIP SEC./LOT NONPROD. WELL NO./ LEASE NAME DNR 5616 (Rev. 04/2012) Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com CHANGE OF OWNER INSTRUCTIONS The Division of Oil and Gas Resources Management has a revised Request for Change of Owner (Form 7). This form is to be submitted to the Division within thirty (30) days after the date of assignment or transfer of a well (Section 1509.31, Ohio Revised Code). The Request for Change of Owner (Form 7) is to be accompanied by a non-refundable fee of $100.00 per well. Make checks payable to the Division of Oil and Gas Resources Management. This form is to be initiated by the assignor/transferor. The assignor/transferor is the individual or company selling or transferring the well. It is his responsibility to see that the form is completed because the assignor/transferor is liable for this well under Chapter 1509. of the Ohio Revised Code and Chapter 1501. of the Ohio Administrative Code until they receives an acknowledgment from the Division that it has been transferred. The assignee/transferee is the individual or company buying the well or becoming the owner as defined under Section 1509.01(K), ORC. The permit number must be on the form. This number can be taken directly from the permit. Both parties must complete and notarize the form before it is forwarded to the Division. The transfer must be the original copy and may be used to transfer an individual well or multiple wells. THE ASSIGNEE/TRANSFEREE MUST BE IN COMPLIANCE WITH THE BONDING AND LIABILITY INSURANCE REQUIREMENTS (SECTION 1509.07, OHIO REVISED CODE) BEFORE THE REQUEST CAN BE PROCESSED AND NOT BE IN MATERIAL AND SUBSTANTIAL VIOLATION OF CHAPTER 1509., ORC OR CHAPTER 1501., OA