Fillable Printable Affidavit of Loss - Colorado

Affidavit of Loss - Colorado

Affidavit of Loss

State of _________ )

) ss.

County of _________ )

The Affiant, _________________, (title), of lawful age, being first duly sworn states and

avers:

1. That (Lessee Name) is the original lessee of Colorado Oil and Gas Lease

No.(s) ____________________________________________________.

2. That the original of this state lease was in possession of (Lessee Name) as

is customary with State of Colorado oil and gas leases and all original

previous state assignments in ch ain of title.

3. It was approximately ___ years ago that this oil and gas lease was issued

to the Affiant. The Affiant has very recently checked his records and

cannot locate this oil and gas lease(s) and so m ust assume that it is lost.

FURTHER Affiant sayeth not.

______________________________

Signed

Subscribed and sworn to before me, a Notary Public this ______day of__________, 2009

by ____________________________.

My Commission expires ______________________.

(STAMP) ______________________________

Notary Public