Affidavit of Loss
State of _________ )
County of _________ )
The Affiant, _________________, (title), of lawful age, being first duly sworn states and
1. That (Lessee Name) is the original lessee of Colorado Oil and Gas Lease
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.
Subscribed and sworn to before me, a Notary Public this ______day of__________, 2009
My Commission expires ______________________.