The Ohio Department of Natural Resources

STATE OF OHIO THE OHIO DEPARTMENT OF NATURAL RESOURCES THE DIVISION OF OIL AND GAS RESOURCES MANAGEMENT 2045 MORSE ROAD, BUILDING F-2 COLUMBUS, OHIO 43229-6693

ROAD USE MAINTENANCE AFFIDAVIT

Application No.

Being first duly sworn according to law, depose and attest that I attempted in good faith to enter into a Road Use Maintenance Agreement with the public official that has the legal authority of each county, township or municipal corporation, as indicated below, and that no agreement was executed. Attach any supporting correspondence.

Name of Public Official Title Affiliation Date

Further affiant sayeth naught.

Signature

SWORN to before me and subscribed in my presence this

Notary Public:

DNR-734-7012