Request For Waiver Form - For Bond To Protect Surface - 2004

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New Mexico State Land Office – Oil, Gas, and Minerals Division
REQUEST FOR WAIVER --
ON LINE VERSION
For Bond to Protect Surface
_____________________________________________________________________ requests a waiver from the
(Lessee – Assignee – Grantor – Operator)
State of New Mexico, Commissioner of Public Lands, for a surface damage bond needed to process an
assignment of oil and gas lease #________________ from _______________________________________
(Assignor)
to ___________________________________________________________________
.
(Assignee)
Subdivisions ________________________________________________________________________________________________,
Sect _________, Twp _________, Rng _________, NMPM in __________________________________________________ COUNTY, NM.
No surface disturbance or occupation of the lands is anticipated at this time.
In the event any operations are deemed to be conducted, a surface damage bond will be procured
to protect any damage or disturbance to interests and tangible improvements in behalf of patentee
and/or surface lessees.
__________________________________________________________________
PRINT or TYPE Name of COMPANY or of INDIVIDUAL Person requesting waiver.
By_____________________________________________________________________ ____________________________________________
PRINT or TYPE Name and Title of company representative
SIGNATURE of Representative or of Individual
Acknowledgment in an Individual Capacity
State of ______________________________
ss
County of _____________________________
This instrument was acknowledged before me this _______day of ________________________, 20______
By _____________________________________________________________________________________
Name(s) of Person(s)
___________________________________________
Signature of Notarial Officer
(Notary Seal)
My commission expires ___________________
Acknowledgment in a Representative Capacity
State of _____________________________
ss
County of ____________________________
This instrument was acknowledged before me this _______day of ________________________, 20______
By____________________________________________________________________________________
Name of Person
as __________________________________________ of ______________________________________________
Title, type of authority; e.g., officer, trustee, etc.
Name of party on behalf of whom instrument was executed
_____________________________________
Signature of Notarial Officer
(Notary Seal)
My Commission expires ___________________
Online version – November 2004

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