FORM
WW-60
(5-01)
DATE: _________________, 19 ______
OPERATOR'S
WELL NO. _________________________
API NO: 47-
State County
Permit No.
STATE OF WEST VIRGINIA
OFFICE OF OIL AND GAS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
A F F I D A V I T
State
of ____________________________
County
of ___________________________
I, ____________________________(the designated owner or operator, or
authorized representative thereof), after being duly sworn, do declare that the
undersigned is authorized by the owner of the working interest in the well
permit application to which this affidavit is attached to state that (he,
she, or it) shall tender to the owner of the oil and gas in place
not less than one-eighth of the total amount paid to or received by or allowed
to the owner of the working interest at the wellhead for the oil or gas so
extracted, produced, or marketed before deducting the amount to be paid or set
aside for the owner of the oil or gas in place, or all such oil or gas to be
extracted, produced, or marketed from the well. West Virginia Code 22-6-8(e).
Signed:
______________________________________________
Taken, subscribed and sworn to before me this _______ day of
___________________, 19 _______.
___________________________________
Notary Public
My
Commission expires: _________________________
www.msngr.org