Affidavit of Loss
State of _________ )
County of _________ )
The Affiant, _________________,_________________ (title), of lawful age, being first
duly sworn states and avers:
1. That _______________________(cu rren t lessee name) is the original lessee of
Colorado Oil and Gas Lease No.________.
2. That the original of this state lease was in possession of
_______________________(cu rren t lessee name) as is customary with State of
Colorado oil and gas leases.
3. It was approximately ___ year(s) ago that this oil and gas lease and all
original previous state assignments in chain of title was issued to the
Affiant. The Affiant has very recently checked his records and cannot
locate this oil and gas lease and so must assume that it is lost.
FURTHER Affiant sayeth not.
Subscribed and sworn to before me, a Notary Public this ____day of__________, 20___.
My Commission Expires ______________________.