Split a Permit Affidavit

Application to Split A Permit and Request for Oregon Water Resources Department Issuance of Replacement 725 Summer Street NE, Suite A Salem, Oregon 97301-1266 Permits (503) 986-0900 www.wrd.state.or.us Affidavit of Non-Conveyance and Reading of Permit

State of Oregon ) ) ss County of )

I/We, , mailing address , telephone number ( ) , being first duly sworn depose and say:

1. Permit , has not been conveyed or withheld and remains appurtenant to my/our land.

2. I/We attest that I/we have read Permit .

______Signature of Affiant Date

Signed and sworn to (or affirmed) before me this _____ day of ______, 20____.

______Notary Public for Oregon

My Commission Expires: ______

Version 12/16/2014 Split a Permit Affidavit TACS