DELETE AFTER READING: Before Entering Data, SAVE AS Under a Separate File Name. Use The

DELETE AFTER READING: Before entering data, “SAVE AS” under a separate file name. Use the TAB key to move to each field. Repeated info will auto- populate throughout the form. If the fields do not auto-update (page #), right-click and select Update Field. QUIT CLAIM DEED (MINERAL SURFACE RIGHTS) WITH LIMITATION OF ACCESS

Form MQCD-5 Project: PROJECT # Revised 07/2014 Code: CODE Parcel: PARCEL # Page: 1 of 3 THIS INDENTURE WITNESSETH, That GRANTOR(S), the Grantor(s) of GRANTOR COUNTY County, State of RANTOR STATE Release(s) and Quit Claim(s) to the STATE OF INDIANA, the Grantee, for and in consideration of the sum of DOLLAR AMOUNT (Text) Dollars ($0.00) and other valuable consideration, the receipt of which is hereby acknowledged, all right, title, interest and possessory rights which the Grantor(s) may have in, to or upon the surface of certain Real Estate situated in the County of COUNTY OF PROPERTY, State of Indiana, and being more particularly described in the legal description(s) attached hereto as Exhibit “A” and the Right of Way Parcel Plat attached hereto as Exhibit “B”, which exhibits are incorporated herein by reference, together with right to mine, drill, explore, extract or in any way enter upon, or penetrate the surface of, said Real Estate to exercise any rights to any minerals located thereunder (the term “minerals” including, but being limited to, coal, gas, oil, peat, salt, sand, stone, aggregates, and all other such resources). TOGETHER with the permanent extinguishment of all rights and easements of ingress and egress to, from and across the highway facility known as ROAD and as Project PROJECT # to and from the surface of the lands which have been or are subjected to the rights of the Grantor(s) herein where the said lands abut the Real Estate. This restriction is a covenant running with the land and shall be binding on the Grantor(s) and the Grantor(s) successors in title to the said abutting lands. << insert jurat(s) here - otherwise delete >>

Interests in land acquired by the Indiana Department of Transportation Grantee mailing address: 100 North Senate Avenue N642 Indianapolis, IN 46204-2219 I.C. 8-23-7-31 Form MQCD-5 Project: PROJECT # Revised 07/2014 Code: CODE Parcel: PARCEL # Page: 2 of 3

IN WITNESS WHEREOF, the said Grantor(s) has / have executed this instrument this ______day of ______, ______. COMPANY NAME (Seal) (Seal) Signature Signature

NAME, TITLE, IF APPLICABLE (or delete) NAME, TITLE, IF APPLICABLE (or delete) Printed Name Printed Name

(Seal) (Seal) Signature Signature

NAME, TITLE, IF APPLICABLE (or delete) NAME, TITLE, IF APPLICABLE (or delete) Printed Name Printed Name

STATE OF: ______: SS: COUNTY OF ______:

Before me, a Notary Public in and for said State and County, personally appeared ______, the Grantor(s) in the above conveyance, and acknowledged the execution of the same on the date aforesaid to be his / her / their voluntary act and deed and who, being duly sworn, stated that any representations contained therein are true.

Witness my hand and Notarial Seal this ______day of ______, ______.

Signature

Printed Name ______

My Commission expires ______

I am a resident of ______County.