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OHIO DEPARTMENT OF NATURAL RESOURCES DIVISION OF OIL & GAS RESOURCES MANAGEMENT
2045 MORSE RD., F-2, COLUMBUS, OH 43229-6693 Phone: (614) 265-6922 • Fax: (614) 265-6910
ROAD USE MAINTENANCE AFFIDAVIT
DNR—734-7012 Page 1 of 1
Application No.
Being first duly sworn according to law, depose and attest that I attempted in good faith to enter into a Road
Use Maintenance Agreement with the public official that has the legal authority of each county, township or
municipal corporation, as indicated below, and that no agreement was executed. Attach any supporting
correspondence.
Name of Public Official Title Affiliation Date
Further affiant sayeth naught.
Signature
SWORN to before me and subscribed in my presence this
Notary Public:
Application Number: Official 1: Title 1: Affiliation 1: Date 1: Official 2: Title 2: Affiliation 2: Date 2: Official 3: Title 3: Affiliation 3: Date 3: Official 4: Title 4: Affiliation 4: Date 4: Official 5: Title 5: Affiliation 5: Date 5: Official 6: Title 6: Affiliation 6: Date 6: