lnstructions OKLAHOMA CORPORATION COMMISSION This form must be filed with the Form 1073 A. Please type or print using black or blue ink. Oil & Gas Conservation Division OCC within 30 days of transit Rev. 2017 B. Form must be signed by former operator and new operator. Post Office Box 52000 of the well. C. Signatories be listed on their companys Form Oklahoma City, OK 73152-2000 D. Fill in the complete legal description below. FEE: $25.00 Transfer of Operator E. Direct questions to Well Records (405) 521-2271. Single Oil or Gas Well OAC 165:5-3-1(6(tj1N) OAC 165:10-1-15 API No i \ n , r i - 1 ...... L- a( % — I -4. .0 i - OTC Prod Unit No. Surface Location Sec . 1 Twp 22N Rge 4E SE SE SE 1/4 1/4 1/4 1/4 Ft FSL of 330 Qtr Sec Ft FWL of 2310 Qtr Sec County Pawnee Current Well Diane-Dennis # 1-2 Name/Number Original Well 4511,24922-- Name/Number Unit Name (if applicable) Well Class: MOIL [ JGAS EIDRY (SEE K PAGE FOR AYMENT INFORMATION) DO NOT WRITE INSIDE THIS BOX OKLA CUkF COPIA :W23 - 15/05/2017 Time: 13:35 Case: 000000000 Cashier: RE Payor: .7O1iN M PARKS Check: 34:12 $25.00 50 WELL TRANSFER-OFER Use this form to transfer stngle oil or gas wells only. Use Form 3MW to transfer 1 0 or Specify a we 1i 0 ND 0 SP I status: (see back page) AC El TA 0 TM Producing formation(s) The effective date of j is the date transfer of this well, for the purposes of Commission records, that the transfer is ap roved by pie Commission. CURRENT OPERATOR OCC/OTC No. C . tA.901, g- - 1/ t) 20153 NEW OPERATOR OCC/OTC No. 21519 Name Myers Operating Address PO Box 285 City Pawnee OK State IZip 74058 Phone No. 580-623-3500 FAX No./E-mail 44 11 0L414,54.9- I verify that I am the legal operator of operatorship of this well, that the facts and that I have completed this form as (Signa must be listed on companys record with authority to transfer presented herein are true and correct, required by the above instructions. Form 10068 Operator's Agreement) Signature .1ND reA /h yet , s - Q...6 0 e .^ - --et Li 61-1 ' 4 - / , Name & Title (Typed or Printed) Signed and swom to before me this 4.1 ' day 2.,e/ 7 ...... ,2/ of , . II ,,._w i Ct..4;e 1 ....... „.___z4 - .......A...e..- Notary Public I My commission expires: a / -9 /..70 .._y 0 4/ 1 Name Osburn Geralidba Ozzy & Son Oil & Gas- Effie Osburn Address 11921 S. 513th West Ave City Drumright State Zip OK 74030 Phone No. 918-352-4840 FAX No /E-mail Being the new operator, as of the effective date of transfer, I accept the facts presented as being true and correct and accept the operational responsibility for the well on the described property. (Signatory must be listed on company's Form 1006B Operator's Agreement) _ Name & Title (Typed or Printed) Signed and swom to before me C LLIN ,0%.11 ARYMNtK—STATE OF MAKI 00111MIS610N * 16011910 2011 l verify under oath that l have exercised due diligence in attempting to locate the current operator of record according to OCC records, who has abandoned the listed well/lease and cannot be located to obtain signature. I have attached a ;led copy of the recorded iease or assignment, or certified copies of a joumal entry of judgment or bankruptcy pr ing pursuant tp OAC 165:10-1-15( oc i Signed and sworn to before me this My commission expires: day of Sig -6.fr7( 9 / FOR OCC USE ONLY Surety Approved Date Well Records Review: MU (15 70,17 MAY 05 2017 E. 7,ECORDS . -\ POROVED U. Notarv Public By processing this Form 1073, the Oklahoma Corporation Commission has approved the contents thereof as to torm only. The Oklahoma Corporation Commission does not warrant that the facts provided by the operator are true. Transfer is not effective until approved by the Well Records Department.