Affidavit of Non-Production - DOC by HC120626062428


									                                                                                             Affidavit of Non-Production

                                                                                          Recorder’s Use


State of Illinois                             )
                                              ) ss
County of                                     )

                                    ,being first duly sworn on his oath, states that he is familiar with the following described
property, to-wit:
which property is covered by an oil and gas lease dated the              day of,                                  , recorded in the
Recorder’s Office of                      County in Book                   on Page                  by
as lessor, in favor of                              as lessee, that he knows of his own knowledge that no production of oil or
gas has ever been obtained upon any of the above described property, over the last                  years.

State of Illinois                             )
                                              ) ss
County of                                     )

       I,                                              , a Notary Public, in and for said County and State aforesaid, do
hereby certify that                                                    who                         , personally known to
me to be the same person                                 , whose name                                 , subscribed to the
foregoing instrument, appeared before me this day in person and acknowledged that he/she                          signed,
sealed and delivered the said instrument as                                       free and voluntary act, for the uses and
purposes therein set forth.

Given under my hand and notarial seal this                      day of                              ,               .

                                                                                   Notary Public

                                                                                 My commission expires:

The recorded copy of this form must be submitted to the Illinois Department of Transportation, Division of Aeronautics,
1 Langhorne Bond Drive, Springfield, IL 62707-8415, Attn: Land Acquisition. To expedite processing this completed
signed form may be scanned and emailed to or faxed to (217)785-4533.

Printed 6/26/2012                                                                                              AER 2467 (07/15/10)

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