Form Ogb-28 - Master Electronic Filing Certification - State Oil And Gas Board Of Alabama

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STATE OIL AND GAS BOARD OF ALABAMA

OGB-28

Master Electronic Filing Certification

New

Amended

Annual

Form OGB-28, Rev. 07/13

(File in triplicate)

This certification shall be submitted annually or immediately after any change occurs as to facts submitted.

Full Name of the Company, Organization, or Individual __________________________________________________________________________

Street Address (required) _________________________________________________________________________________________________

Post Office Address _____________________________________________________________________________________________________

City ____________________________ County _________________________ State _____________________ Zip _____________________

Plan of organization _____________________________________________________________________________________________________

(corporation, general or limited partnership, limited liability company, sole proprietorship, or individual)

DESIGNATION OF OPERATOR’S AUTHORIZED AGENT

Name of authorized agent _________________________________________________________ Title __________________________________

Address ______________________________________________ City _______________________ State __________ Zip ________________

Phone number __________________ Fax number __________________ E-Mail address ____________________________________________

Remarks:

The signature of the operator or the operator’s authorized agent affixed to this master certification shall be, and is hereby, deemed to certify

that each document filed electronically was, in fact, filed on behalf of the operator named above in this certification. Further, the signature of

the operator or the operator’s agent or representative affixed to the master certification shall be, and is hereby, deemed to certify that the

representative of the operator had knowledge of the facts contained on the document filed electronically and the facts contained on each

document filed electronically are true and correct.

The operator and its authorized agent shall comply with all rules and procedures established by the State Oil and Gas Board for electronic

filing. The operator and its authorized agent shall also comply with any changes in the rules and procedures adopted by the State Oil and

Gas Board for electronic filing. Such changes are incorporated herein as if set out in full.

________________________________________________________

________

Executed this the _______ day of __________

, 20 __

Signature of Operator or Authorized Agent

________________________________________

Before me, the undersigned authority, on this day personally appeared

known to me to be the person

whose name is subscribed to the above instrument, who being by me duly sworn on oath states that he/she is duly authorized to make the above certification and that

he/she has knowledge of the facts stated therein, and that said certification is true and correct.

_______

____________________

_________

Subscribed and sworn to before me this

day of

, 20

______________________________________

SEAL

_____________________

Notary Public in and for

____________________