STATEMENT OF CLAIM OF MINERAL INTEREST

							STATEMENT OF CLAIM OF MINERAL INTEREST
Under the provisions of Chapter 38-18.1 of the North Dakota Century Code, NOTICE IS HEREBY GIVEN, that the undersigned does have, own and claim to be the owner of an undivided interest in and to the oil, gas, coal, clay, gravel, uranium and all other minerals of any kind and nature, unless otherwise noted, underlying the real estate described below in ____________________________________________ County, North Dakota.

FURTHER, that the undersigned desires to preserve such interest as reflected in the office of the County Recorders of said County and does not intend to abandon the same.
(This space reserved for recording information)

Name and address of owner:
___________________________________ ___________________________________ ___________________________________

If not the owner of record, the owner of record is: ___________________________ ___________________________________ Claimant’s relationship to the owner of record is: ___________________________ ___________________________________

EXECUTED THIS ___________ day of ____________________________________, 20____. _________________________________________________________ Owner _________________________________________________________ Owner
STATE OF _____________________________ COUNTY OF ___________________________ ) ) ss )

Notary Seal

On ___________________________________________, _________________________________________ known to me to be the person described in and who executed the foregoing instrument, personally appeared before me and acknowledged that (s)he executed the same as a free act and deed. My Commission Expires Notary Public (Rev - 12/2009)

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