road use maintenance affidavit - ohiodnr.gov...road use maintenance affidavit dnr—734-7012 page 1...

OHIO DEPARTMENT OF NATURAL RESOURCES DIVISION OF OIL & GAS RESOURCES MANAGEMENT

2045 MORSE RD., F-2, COLUMBUS, OH 43229-6693 Phone: (614) 265-6922 • Fax: (614) 265-6910

ROAD USE MAINTENANCE AFFIDAVIT

DNR—734-7012 Page 1 of 1

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:  

Application Number: Official 1: Title 1: Affiliation 1: Date 1: Official 2: Title 2: Affiliation 2: Date 2: Official 3: Title 3: Affiliation 3: Date 3: Official 4: Title 4: Affiliation 4: Date 4: Official 5: Title 5: Affiliation 5: Date 5: Official 6: Title 6: Affiliation 6: Date 6: