Fill and Sign the Affidavit as to Termination of Option Form

AFFIDAVIT AS TO TERMINATION OF OPTION (On Option to Conduct Seismic Activity and Acquire Oil and Gas Lease) State: County: Affiant: (Name and Address) Affiant, on oath, swears that the following statements are true: My name is ____. I am over the age of ____. I am the owner of (all/an undivided interest in) the mineral estate in the following lands (the “Lands”) in the c ounty and state named above: (Description of Lands) On (Date), I entered into an agreement granting (Name of Optionee) an option to conduct seismic activities on the Lands, with an option to acquire an oil and gas lea se on my mineral interest in the Lands, following (Name of Optionee) conducting (his/her/its) seismic survey. The agreement granting the option to conduct seismic activity or geophysical activity on the Lands and acquire an oil and gas lease on the Lands is recorded in Volume ____, page ____ of the ____ Records of the county in which the Lands are located. (Name of Optionee), or (his/her its), successors and assigns never exercised the option to acquire an oil and gas lease on my mineral interest in the Lands. The time period provided for in the Option for (Name of Optionee) to acquire an oil and gas lease on my mineral inte rest in the Lands has elapsed. The agreement granting the option to acquire an oil and gas lea se on my mineral interest in the Lands is no longer valid and is deemed by me to have e xpired and terminated. This Affidavit is signed by me on the date of acknowledgment of my signature. Affiant (Jurat) (Acknowledgment)