Appendix A - SAMPLE PETITIONS AND FORMS
PETITION FOR CHANGE OF POINT ) OF DIVERSION OF THE FOLLOWING ) APPROPRIATIONS: )
A. THE JONATHAN J. DOE ) APPROPRIATION, TERRITORIAL ) APPROPRIATION, DIVERTING FROM ) NO NAME CREEK, TRIBUTARY NO ) BEFORE THE NAME RIVER, THROUGH THE NO ) STATE BOARD OF CONTROL NAME DITCH, WITH PRIORITY OF ) CHEYENNE, WYOMING MAY 16, 18 85; )
B. THE JANE ALEXANDRA DOE ) APPROPRIATION, PERMIT NO. 3214 ) ENL., DIVERTING FROM NO NAME ) CREEK, TRIBUTARY NO NAME ) RIVER, THROUGH THE ENLARGED NO ) NAME DITCH, WITH PRIORITY OF ) OCTOBER 9, 1922. )
O.R. 2, P. 446; C.R. 2, P. 435; PROOF NO. 1491
O.R. 7, P. 123; C.R. 32, P. 436; PROOF NO. 11411
STATE OF WYOMING )
) SS
COUNTY OF FREMONT )
COMES NOW John Doe of Box 00, Lander, County of Fremont, State of Wyoming, who being duly sworn on oath according to law does hereby make the following statement of facts and petition:
1. THAT he is the owner of the lands and the appropriations involved as evidenced by the attached proof of ownership from the County Clerk of Fremont County, Wyoming.
2. THAT the appropriations involved are as follows:
a. The Jonathan J. Doe Appropriation, Territorial Appropriation, adjudicated under Proof No. 1491, in the amount of 0.57 c.f.s. for the irrigation of 40.0 acres, diverting from No Name Creek, tributary No Name River, through the No Name Ditch, with priority of May 16, 1885, and of record in Order Record 2, page 446; Certificate Record 2, page 435 describing the lands irrigated as follows:
| Township 30 North, Range 100 West | |
| Section 17: NW1/4SW1/4 | 2 5.0 acres |
| SW1/4SW1/4 | 15.0 |
| Total | 40.0 acres (0.57 c.f.s.) |
b. The Jane Alexandra Doe Appropriation, Permit No. 3214 Enl., adjudicated under Proof No. 11411, in the amount of 1.71 c.f.s. for the irrigation of 120.0 acres, diverting from No Name Creek, tributary No Name River, through the No Name Ditch, with priority of October 9, 1922, and of record in Order Record 7, page 123; Certificate Record 32, page 436 describing the lands irrigated as follows:
| Township 30 North, Range 100 West | |
| Section 16: SW1/4NW1/4 | 10.0 acres |
| NW1/4SW1/4 | 10.0 |
| Section 17: SE1/4NE1/4 | 2 0.0 |
| NE1/4SE1/4 | 4 0.0 |
| SE1/4SE1/4 | 40.0 |
| Total | 120.0 acres (1.71 c.f.s.) |
3. THAT your petitioner desires to change the point of diversion of the No Name Ditch, Territorial Appropriation, and Permit No. 3214 Enl., from its point of diversion of record on No Name Creek, described as North 10° 15' West, 320.0 feet distant from the Southeast Corner of Section 13, Township 30 North, Range 100 West, and situated in the SE1/4SE1/4 of Section 13, to a new point of diversion diverting from the same source of supply approximately 500 feet downstream at a point described as North 20° 10' East, 600.0 feet distant from the Southwest Corner of Section 18, Township 30 North, Range 99 West, and situated in the SWSW1 of Section 18.
The lands for which this change is requested are described as follows:
A. The Jonathan J. Doe Appropriation, Territorial Appropriation, Proof No. 1491:
| Township 30 North, Range 100 West | |
| Section 17: NW1/4SW1/4 | 2 5.0 acres |
| SW1/4SW1/4 | 15.0 |
| Total | 40.0 acres (0.57 c.f.s.) |
B. The Jane Alexandra Doe Appropriation, Permit No. 3214 Enl., Proof No. 11411:
| Township 30 North, Range 100 West | |
| Section 16: SW1/4NW1/4 | 10.0 acres |
| NW1/4SW1/4 | 10.0 |
| Section 17: SE1/4NE1/4 | 2 0.0 |
| NE1/4SE1/4 | 4 0.0 |
| SE1/4SE1/4 | 40.0 |
| Total | 120.0 acres (1.71 c.f.s.) |
Total acreage to be changed to the new point of diversion is 160.0 acres (2.28 c.f.s.).
4. THAT this proposed change of point of diversion is necessary because flooding through No Name Creek has washed a deep channel at the site of the present headgate. The new proposed point of diversion will provide a more practical point to install a permanent headgate.
5. THAT there are no record intervening points of diversion (headgates) between the point of diversion of record of the No Name Ditch and the proposed new point of diversion of the No Name Ditch.
6. THAT there are no intervening tributaries or other sources of supply which might affect the rights of other appropriators.
7. THAT a properly prepared map showing the actual situation on the ground accompanies this petition.
8. THAT the granting of this petition will not injure any other appropriators. It is the prayer of your petitioner that this petition for change of point of diversion, as outlined in paragraph 3 above, be allowed without loss of priority, and that a proper Order of the Board be entered recording same.
Respectfully submitted,
____________________
John Doe
The foregoing instrument was acknowledged before me this ___ day of __________________, 20______.
Witness my hand and official seal.
______________________
Notarial Officer
My Commission expires: _____________________________________
PETITION FOR CHANGE OF POINT )
OF DIVERSION AND MEANS OF )
CONVEYANCE OF THE J. W. DOE )
APPROPRIATION, PERMIT NO. ) BEFORE THE
3214, DIVERTING FROM NO NAME ) STATE BOARD OF CONTROL
CREEK, TRIBUTARY NO NAME ) CHEYENNE, WYOMING
RIVER, THROUGH THE NO NAME )
DITCH, WITH PRIORITY OF MAY )
16, 19 05, TO BE CHANGED TO THE )
UNNAMED DITCH. )
O.R. 2, P. 446; C.R. 3, P. 435; PROOF NO. 3491
STATE OF WYOMING )
) SS
COUNTY OF FREMONT )
COMES NOW John Doe of Box 00, Split Rock, County of Fremont, State of Wyoming, who being duly sworn on oath according to law does hereby make the following statement of facts and petition:
1. THAT he is the owner of the lands and the appropriation for which a change of point of diversion and means of conveyance is sought, as evidenced by the attached proof of ownership from the County Clerk of Fremont County, Wyoming.
2. THAT the appropriation for which a change of point of diversion and means of conveyance is sought is the J. W. Doe Appropriation, Permit No. 3214, adjudicated under Proof No. 3491, in the amount of 0.89 c.f.s. for the irrigation of 62.0 acres, diverting from No Name Creek, tributary No Name River, through the No Name Ditch, with priority of May 16, 1905, and of record in Order Record 2, page 446; Certificate Record 3, page 435 describing the lands irrigated as follows:
| Township 30 North, Range 98 West | |
| Section 19: SW1/4SW1/4 | 32.0 acres |
| SE1/4SW1/4 | 10.0 |
| Section 30: NW1/4NW1/4 | 20.0 |
| Total | 62.0 acres (0.89 c.f.s.) |
3. THAT your petitioner requests a change of point of diversion and means of conveyance of the J. W. Doe Appropriation, Permit No. 3214, which diverts from No Name Creek through the No Name Ditch, at a point described as North 12° 30' East, 1620.0 feet distant from the Southwest Corner of Section 28, Township 30 North, Range 99 West, and situated in the SESW1 of Section 28, to the Unnamed Ditch, diverting from the same source of supply, under Permit No. 3400, approximately H mile downstream at a point described as North 15° 20' East, 1056.0 feet distant from the Southwest Corner of Section 28, Township 30 North, Range 99 West, and situated in the SW1/4SW1/4 of Section 28.
The lands for which this change is requested are described as follows:
| Township 30 North, Range 98 West | |
| Section 19: SW1/4SW1/4 | 32.0 acres |
| SE1/4SW1/4 | 10.0 |
| Section 30: NW1/4NW1/4 | 20.0 |
| Total | 62.0 acres (0.89 c.f.s.) |
4. THAT the reason for the requested change is that a portion of the No Name Ditch is subject to washouts and has been difficult to maintain. A change of point of diversion and means of conveyance to the Unnamed Ditch will eliminate this problem and provide a more economical means of conveyance.
5. THAT consent from Robert Smith, sole owner of the Unnamed Ditch, Permit No. 3400, accompanies this petition.
6. THAT there are no record intervening points of diversion (headgates) between the point of diversion of the No Name Ditch and the point of diversion of the Unnamed Ditch.
7. THAT there are no intervening tributaries or other sources of supply which might affect the rights of other appropriators.
8. THAT a properly prepared map showing the actual situation on the ground accompanies this petition.
9. THAT the granting of this petition will not injure any other appropriators. It is the prayer of your petitioner that this petition for change of point of diversion and means of conveyance, as outlined in paragraph 3 above, be allowed without loss of priority, and that a proper Order of the Board be entered recording same.
Respectfully submitted,
________________
John Doe
The foregoing instrument was acknowledged before me this ___ day of __________________, 20______.
Witness my hand and official seal.
___________________
Notarial Officer
My Commission expires: _____________________________________
PETITION FOR AN AMENDED )
CERTIFICATE OF APPROPRIATION )
FOR THE JONATHAN W. DOE )
APPROPRIATION, TERRITORIAL ) BEFORE THE
APPROPRIATION, DIVERTING FROM ) STATE BOARD OF CONTROL
NO NAME CREEK, TRIBUTARY NO ) CHEYENNE, WYOMING
NAME RIVER, THROUGH THE NO )
NAME DITCH, WITH PRIORITY OF )
APRIL 21, 188 6. )
O.R. 2, P. 446; C.R. 2, P. 435; PROOF NO. 1491
STATE OF WYOMING )
) SS
COUNTY OF SUBLETTE )
COMES NOW John Doe of Box 00, Big Piney, County of Sublette, State of Wyoming, who being duly sworn on oath according to law does hereby make the following statement of facts and petition:
1. THAT he is the owner of the lands and the appropriation for which an amended certificate of appropriation is sought, as evidenced by the attached proof of ownership from the County Clerk of Sublette County, Wyoming.
2. THAT the appropriation for which an amended certificate is sought is the Jonathan W. Doe Appropriation, Territorial Appropriation, adjudicated under Proof No. 1491, in the amount of 2.71 c.f.s. for the irrigation of 190.0 acres, diverting from No Name Creek, tributary No Name River, through the No Name Ditch, with priority of April 21, 1886, and of record in Order Record 2, page 446; Certificate Record 2, page 435 describing the lands irrigated as follows:
| Township 29 North, Range 111 West | |
| Section 14: SE1/4 | |
| Section 23: N1/4NE1/4 | _____ |
| Total | 190.0 acres (blanket description) |
3. THAT your petitioner requests that an amended certificate of appropriation for the Jonathan W. Doe Appropriation, Territorial Appropriation, Proof No. 1491, be issued as follows:
| Township 29 North, Range 111 West | |
| Section 14: NE1/4SE1/4 | 10.0 acres |
| NW1/4SE1/4 | 2 0.0 |
| SW1/4SE1/4 | 4 0.0 |
| SE1/4SE1/4 | 4 0.0 |
| Section 23: NE1/4NE1/4 | 4 0.0 |
| NW1/4NE1/4 | 25.0 |
| Total | 175.0 acres (2.50 c.f.s.) |
This amendment results in the reduction of 15.0 acres (0.21 c.f.s.) under this appropriation.
4. THAT the reason for this amendment is to describe those lands which have been historically irrigated and are currently being irrigated and to correct the records to agree with the actual situation on the ground.
5. THAT recording fees in the amount of __________________ accompany the petition.
6. THAT a properly prepared map showing the actual situation on the ground accompanies this petition.
7. THAT the granting of this petition will not injure any other appropriators.
It is the prayer of your petitioner that a proper Order of the State Board of Control be entered to describe the lands under the Jonathan W. Doe Appropriation, as outlined in paragraph 3 above, and that an amended certificate of appropriation be issued for the same.
Respectfully submitted,
____________________
John Doe
The foregoing instrument was acknowledged before me this ___ day of __________________, 20______.
Witness my hand and official seal.
___________________
Notarial Officer
My Commission expires: _____________________________________
PETITION FOR CHANGE OF USE )
FROM IRRIGATION TO MUNICIPAL )
USE AND CHANGE OF POINT OF )
DIVERSION AND MEANS OF )
CONVEYANCE OF THE J. W. DOE ) BEFORE THE
APPROPRIATION, TERRITORIAL ) STATE BOARD OF CONTROL
APPROPRIATION, DIVERTING FROM ) CHEYENNE, WYOMING
NO NAME RIVER THROUGH THE NO )
NAME DITCH, WITH PRIORITY OF )
MAY 16, 18 85, TO BE CHANGED TO )
THE NO NAME MUNICIPAL )PIPELINE.)
O.R. 2, P. 446; C.R. 2, P. 30; PROOF NO. 919
STATE OF WYOMING )
) SS COUNTY OF NATRONA )
COMES NOW the Town of Rodgers, acting through its Mayor, James J. Jones, of P.O. Box 40, Rodgers, County of Natrona, State of Wyoming, who being duly sworn on oath according to law, does hereby make the following statements of fact and petition:
1. THAT the Town of Rodgers is the owner of the appropriation for which a change of use and change of point of diversion and means of conveyance is sought as evidenced by an Authorization to Detach Water Right which accompanies this petition.
2. THAT the appropriation for which a change of use from irrigation to municipal use and change of point of diversion and means of conveyance is sought is the J. W. Doe Appropriation, Territorial Appropriation, adjudicated under Proof No. 919, in the amount of 1.0 c.f.s. for the irrigation of 70.0 acres, diverting from No Name River through the No Name Ditch, with priority of May 16, 1885, and of record in Order Record 2, page 446; Certificate Record 2, page 30 describing the lands irrigated as follows:
| Township 38 North, Range 79 West | |
| Section 13: NE1/4NW1/4 | 35.0 acres |
| NW1/4NW1/4 | 35.0 |
| Total | 70.0 acres (1.0 c.f.s.) |
3. THAT water under this appropriation has been applied to beneficial use upon the lands in accordance with statutory provisions, and your petitioner desires to change the use of same from irrigation to a preferred use for municipal purposes to be used within the city limits of the Town of Rodgers described as follows:
| Township 39 North, Range 78 West |
| Section 6: EH |
| Section 5: WHWH |
4. THAT your petitioner also requests a change of point of diversion and means of conveyance of the J. W. Doe Appropriation, as changed from irrigation to municipal purposes, from its record point of diversion on the No Name River described as South 25° 10' East, 273.0 feet distant from the Northwest Corner of Section 13, Township 38 North, Range 79 West, and situated in the NW1/4NW1/4 of Section 13, to the No Name Municipal Pipeline, a new facility, which diverts from the same source of supply approximately 4 miles downstream at a point described as South 27° 5' East, 9 6 9.0 feet distant from the West Quarter Corner of Section 6, Township 39 North, Range 78 West, and situated in the NW1/4SW1/4 of Section 6.
5. THAT there are two (2) record intervening points of diversion between the point of diversion of the No Name Ditch and the point of diversion of the No Name Municipal Pipeline. These intervening points of diversion are for the following facilities:
No Flow Ditch, Permit No. 235
Full Flow Ditch, Permit Nos. 45 6 and 12 3 Enl.
6. THAT consents from the owners of these intervening facilities accompanies the petition.
7. THAT a consumptive use study prepared by John W. Stag, a registered professional engineer, accompanies the petition. This study indicates the consumptive use is 48%. Therefore, your petitioner requests that 0.48 c.f.s. of the J. W. Doe Appropriation be changed from irrigation to municipal purposes and that the remaining 0.52 c.f.s. will not be diverted and will remain in the system to satisfy return flows.
8. THAT a properly prepared map showing the location of lands from which the appropriation is to be detached, the new points of use, and the location of the No Name Municipal Pipeline accompanies the petition.
9. THAT recording fees in the amount of __________________ accompany the petition.
10. THAT the granting of this petition will not injure any other appropriators. It is the prayer of the petitioner:
A. THAT the appropriation of water herein described, which has been acquired by the Town of Rodgers, be changed from irrigation to municipal purposes for use within the city limits of the Town of Rodgers;
B. THAT the point of diversion and means of conveyance for the J. W. Doe Appropriation as changed to municipal purposes be allowed in accordance with paragraph 4 above;
C. THAT a hearing be held as provided by W.S. 41-3-103 and W.S. W.S. W.S. 41-3-104;
D. THAT a proper Order of the State Board of Control be entered recording same and that an amended certificate be issued to the Town of Rodgers.
Respectfully submitted,
____________________
James J. Jones, Mayor
Town of Rodgers
The foregoing instrument was acknowledged before me this day of __________________, 20________.
Witness my hand and official seal.
_____________________
Notarial Officer
My Commission expires: ___________________________________________
PETITION FOR CHANGE OF PLACE )
OF USE OF A PORTION OF THE J. )
W. DOE APPROPRIATION, PERMIT ) BEFORE THE
NO. 7 609, DIVERTING FROM NO ) STATE BOARD OF CONTROL
NAME CREEK, TRIBUTARY NO NAME ) CHEYENNE, WYOMING
RIVER, THROUGH THE NO NAME )
CANAL, WITH PRIORITY OF APRIL )
9, 1902. )
O.R. 17, P. 352; C.R. 68, P. 310; PROOF NO. 282501/2
STATE OF WYOMING )
) SS
COUNTY OF WASHAKIE )
COMES NOW John Doe of 0000 Road 00, Worland, County of Washakie, State of Wyoming, and the J. W. Doe Irrigation District, acting through its Chairman, Buck Doe, of Route 0, Box 000, Worland, County of Washakie, State of Wyoming, whom being duly sworn on oath according to law do hereby make the following statements of facts and petition:
1. THAT John Doe is the present owner of the portion of the appropriation to be affected by this petition, and is included within the boundaries of the J. W. Doe Irrigation District, as evidenced by the copy of Warranty Deed from the County Clerk of Washakie County, Wyoming.
2. THAT the appropriation for which a change of place of use is sought is the J. W. Doe Appropriation, Permit No. 7609, adjudicated under Proof No. 28250, in the amount of 1.79 c.f.s. for the irrigation of 125.0 acres, diverting from No Name Creek, tributary No Name River, through the No Name Canal, with priority of April 9, 1902, and of record in Order Record 17, page 352; Certificate Record 68, page 310 describing the lands irrigated as follows:
| Township 46 North, Range 92 West, Resurvey | |
| Tract 38A: | 14.0 acres |
| Tract 38E: | 22.0 |
| Tract 38F: | 42.0 |
| Tract 38G: | 4.0 |
| Tract 38H: | 43.0 |
| Total | 125.0 acres (1.79 c.f.s.) |
3. THAT your petitioners desire to redescribe this appropriation so as to set out the lands to be irrigated as follows:
The J. W. Doe Appropriation, Permit No. 7609, Proof No. 282501/2:
| Township 46 North, Range 92 West, Resurvey | |
| Tract 38A: | 12.3 acres |
| Tract 38E: | 25.1 |
| Tract 38F: | 39.0 |
| Tract 38G: | 26.9 |
| Section 5: Lot 11 | 0.6 |
| Section 6: Lot 11 | 21.1 |
| Total | 125.0 acres (1.79 c.f.s.) |
4. THAT the reason for the change of place of use is due to the slope and type of soil in the area, which causes erosion problems when flood irrigated. The petitioners are replacing the flood irrigation system with a center pivot sprinkler system to alleviate the erosion problem and to reduce labor costs.
5. THAT recording fees in the amount of __________________ accompany the petition.
6. THAT a properly prepared map showing the actual situation on the ground accompanies this petition.
7. THAT the granting of this petition will not injure any other appropriators.
It is the prayer of your petitioners that a proper Order of the State Board of Control be entered to describe the lands to be irrigated under a portion of the J. W. Doe Appropriation, as shown in paragraph 3 above, and that an amended certificate be issued for the same.
Respectfully submitted,
__________________
John Doe
The foregoing instrument was acknowledged before me this ___ day of __________________, 20______.
Witness my hand and official seal.
_______________
Notarial Officer
My Commission expires: _____________________________________
Respectfully submitted,
________________
Buck Doe, Chairman
J. W. Irrigation District
The foregoing instrument was acknowledged before me this ___
day of __________________, 20______.
Witness my hand and official seal.
_____________________
Notarial Officer
My Commission expires: _____________________________________
PETITION FOR DECLARATION OF )
ABANDONMENT OF THE J. W. DOE )
APPROPRIATION, TERRITORIAL ) BEFORE THE
APPROPRIATION, DIVERTING FROM ) STATE BOARD OF CONTROL
NO NAME CREEK, TRIBUTARY NO ) CHEYENNE, WYOMING
NAME RIVER, THROUGH THE NO )
NAME DITCH, WITH PRIORITY OF )
MAY 16, 18 85. )
O.R. 2, P. 446; C.R. 2, P. 435; PROOF NO. 1281
STATE OF WYOMING )
) SS
COUNTY OF JOHNSON )
COMES NOW John Doe of Box 000, Buffalo, County of Johnson, State of Wyoming, who being duly sworn on oath according to law does hereby make the following statement of facts and petition:
1. THAT your petitioner is the owner of the lands and the following described appropriation of water attached thereto as evidenced by the accompanying proof of ownership from the County Clerk of Johnson County, Wyoming.
The Jane Doe Appropriation, Permit No. 2200, adjudicated under Proof No. 3810, in the amount of 1.53 c.f.s. for the irrigation of 107.0 acres, diverting from No Name Creek, tributary No Name River, through the Unnamed Ditch, with priority of January 15, 1903, and of record in Order Record 3, page 410; Certificate Record 6, page 370 describing the lands irrigated as follows:
| Township 46 North, Range 80 West | |
| Section 12: SE1/4SW1/4 | 30.0 acres |
| SW1/4SE1/4 | 37.0 |
| SE1/4SE1/4 | 40.0 |
| Total | 107.0 acres (1.53 c.f.s.) |
2. THAT James Doe of Box 0, Buffalo, County of Johnson, State of Wyoming, is the owner of record of the lands to which the following described appropriation is attached as evidenced by the accompanying proof of ownership from the County Clerk of Johnson County, Wyoming:
The J. W. Doe Appropriation, Territorial Appropriation, adjudicated under Proof No. 1281, in the amount of 1.47 c.f.s. for the irrigation of 103.0 acres, diverting from No Name Creek, tributary No Name River, through the No Name Ditch, with priority of May 16, 1885, and of record in Order Record 2, page 446; Certificate Record 2, page 435 describing the lands irrigated as follows:
| Township 46 North, Range 80 West | |
| Section 10: NE1/4SE1/4 | 2 0.0 acres |
| SE1/4SE1/4 | 10.0 |
| Section 11: NW1/4SW1/4 | 35.0 |
| SW1/4SW1/4 | 38.0 |
| Total | 103.0 acres (1.47 c.f.s.) |
Total acreage for which a declaration of abandonment is sought by this petition is 103.0 acres (1.47 c.f.s.).
3. THAT your petitioner has standing to file this petition because (fully describe elements of standing here).
4. THAT water under the J. W. Doe Appropriation, Territorial Appropriation, the No Name Ditch, has not been diverted and applied to beneficial use upon the lands described in paragraph 2 above for at least five (5) successive years past, when water was available for this purpose.
5. THAT your petitioner will be benefited by a declaration of abandonment of this appropriation, or injured by the reactivation of this water right, as follows: (fully describe elements of benefit or injury here).
6. THAT recording fees in the amount of __________________ accompany the petition.
It is the prayer of your petitioner that a hearing be held as provided by W.S. W.S. W.S. 41-3-401, and that after the provisions of the statutes have been complied with a proper Order of the State Board of Control be entered declaring an abandonment of the appropriation described in paragraph 2 above.
Respectfully submitted,
________________
John Doe
The foregoing instrument was acknowledged before me this ___ day of __________________, 20______.
Witness my hand and official seal.
_______________
Notarial Officer
My Commission expires: _____________________________________
PETITION FOR VOLUNTARY )
ABANDONMENT OF THE J. W. DOE )
APPROPRIATION, TERRITORIAL ) BEFORE THE
APPROPRIATION, DIVERTING FROM ) STATE BOARD OF CONTROL
NO NAME CREEK, TRIBUTARY NO ) CHEYENNE, WYOMING
NAME RIVER, THROUGH THE NO )
NAME DITCH, WITH PRIORITY OF )
JANUARY 1, 1889. )
O.R. 2, P. 446; C.R. 2, P. 22; PROOF NO. 1491
STATE OF WYOMING )
) SS
COUNTY OF CARBON )
COMES NOW John Doe of Rural Route 0, Canyon, County of Carbon, State of Wyoming, who being duly sworn on oath according to law does hereby make the following statement of facts and petition:
1. THAT he is the owner of the appropriation for which voluntary abandonment is sought as evidenced by the attached proof of ownership from the County Clerk of Carbon County, Wyoming.
2. THAT the appropriation for which voluntary abandonment is sought is the J. W. Doe Appropriation, Territorial Appropriation, adjudicated under Proof No. 1491, in the amount of 1.14 c.f.s. for the irrigation of 80.0 acres, diverting from No Name Creek, tributary No Name River, through the No Name Ditch, with priority of January 1, 1889, and of record in Order Record 2, page 446; Certificate Record 2, page 22; describing the lands irrigated as follows:
| Township 12 North, Range 80 West | |
| Section 2: NE1/4NE1/4 | 30.0 acres |
| NW1/4NE1/4 | 2 0.0 |
| SW1/4NE1/4 | 30.0 |
| Total | 80.0 acres (1.14 c.f.s.) |
3. THAT the No Name Ditch does not exist on the ground and has not existed for many years. Water is not currently being diverted and beneficially used and will not be diverted and beneficially used in the future.
4. THAT your petitioner declares his intention to voluntarily abandon the appropriation described in paragraph 2 above and requests that a proper Order of the Board be entered declaring such abandonment.
5. THAT no fees are required for this petition.
Respectfully submitted,
__________________
John Doe
The foregoing instrument was acknowledged before me this ___ day of __________________, 20______.
Witness my hand and official seal.
_____________________
Notarial Officer
My Commission expires: _____________________________________
APPEAL FROM THE ENDORSEMENT OF )
THE STATE ENGINEER UPON THE ) BEFORE THE
APPLICATION FOR PERMIT TO ) STATE BOARD OF CONTROL
CONSTRUCT THE NO NAME DITCH, ) CHEYENNE, WYOMING
TEMPORARY FILING NO. 00 5/150. )
STATE OF WYOMING )
) SS
COUNTY OF CONVERSE )
COMES NOW John Doe of Bill, County of Converse, State of Wyoming, who being duly sworn on oath according to law does hereby make the following statement of facts and appeal:
1. THAT your appellant filed in the Office of the State Engineer on June 1, 1982, an application, which application was given Temporary Filing No. 00 5/150, to construct the No Name Ditch, and that on July 10, 1982, the State Engineer returned said application with the following endorsement thereon:
"This is to certify that I have examined the foregoing application and have rejected same for the reason that it conflicts with existing rights and threatens to become detrimental to the public interest."
2. THAT your appellant feels himself aggrieved by the said endorsement of the State Engineer as follows:
a. THAT the conflict stated therein may be removed by excluding certain tracts from the application;
b. THAT the allowance of this application is not detrimental to the public interest.
Your appellant, therefore, requests the State Board of Control to hold a hearing as provided by W.S. W.S. W.S. 41-4-517, and that a proper Order be entered upon the records of the State Board of Control reversing the action of the State Engineer.
Respectfully submitted,
_______________
John Doe
The foregoing instrument was acknowledged before me this ___ day of __________________, 20______.
Witness my hand and official seal.
____________________
Notarial Officer
My Commission expires: _____________________________________
PETITION FOR CHANGE OF )
LOCATION OF THE NO NAME WELL, ) BEFORE THE
PERMIT NO. U.W. 3214, WITH ) STATE BOARD OF CONTROL
PRIORITY OF APRIL 3, 1959. ) CHEYENNE, WYOMING
O.R. 16, P. 261; C.R.U.W. 1, P. 38; PROOF NO. U.W. 121
STATE OF WYOMING )
) SS
COUNTY OF ALBANY )
COMES NOW John Doe of Rex Route, Box 20, Laramie, County of Albany, State of Wyoming, who being duly sworn on oath according to law, does hereby make the following statement of facts and petition:
1. THAT he is the owner of the lands irrigated under the well and the appropriation of water to be changed as evidenced by the attached proof of ownership from the County Clerk of Albany County, Wyoming.
2. THAT the well to be relocated is the No Name Well, Permit No. U.W. 3214, the J. W. Doe Appropriation, adjudicated under Proof No. U.W. 121, in the amount of 500.0 gallons per minute for the irrigation of 105.0 acres, with priority of April 3, 1959, and of record in Order Record 18, page 291; Certificate Record U.W. 1, page 38 describing the lands irrigated as follows:
| Township 13 North, Range 75 West | |
| Section 14: SW1/4SE1/4 | 10.0 acres |
| SE1/4SE1/4 | 2 5.0 |
| Section 23: NE1/4NE1/4 | 4 0.0 |
| NW1/4NE1/4 | 30.0 |
| Total | 105.0 acres |
3. THAT your petitioner desires to change the location of the No Name Well, Permit No. U.W. 3214, from its present location described as South 15° 45' West, 125.0 feet distant from the Northeast Corner of Section 23, Township 13 North, Range 75 West, and situated in the NE1/4NE1/4 of Section 23, to a new location described as North 45° 15' West, 48.0 feet distant from the Southeast Corner of Section 14, Township 13 North, Range 75 West, and situated in the SE1/4SE1/4 of Section 14.
4. THAT the lands now irrigated (105.0 acres) and the amount of the appropriation (500.0 g.p.m.) will not be affected by the granting of this petition.
5. THAT the reason for the requested change is that the casing of the present well has deteriorated and a partial cave in has occurred, which drastically reduced the amount of water available. It was determined that it was more economical to relocate the No Name Well than to repair the No Name Well.
6. THAT the proposed new location is within the same ground water basin (aquifer) and as nearly as can be determined, will pump water from the same aquifer.
7. THAT no map is required with this petition but a Letter Certificate of Survey from a licensed Wyoming surveyor describing the new location by tie by distance and direction accompanies this petition.
8. THAT no fees are required for this petition.
9. THAT power records for at least the last five (5) years past which indicates that the well has been beneficially used accompanies the petition.
10. THAT the original No Name Well will be abandoned and sealed in accordance with the State Engineer's Rules and Regulations for wells. A Statement of Completion (Form U.W. 6) will be submitted within 30 days after completion of the new well.
11. THAT the granting of this petition will not injure any other appropriators. It is the prayer of your petitioner that this petition for change of location of the No Name Well as outlined in paragraph 3 above be granted, and that a proper Order of the State Board of Control be entered recording same.
Respectfully submitted,
_______________
John Doe
The foregoing instrument was acknowledged before me this ___ day of __________________, 20______. Witness my hand and official seal.
__________________
Notarial Officer
My Commission expires: _____________________________________
NOTE: If the well is unadjudicated with beneficial use received, there will be no reference to Order Record numbers, Certificate Record numbers and Proof numbers.
THE FOLLOWING FORM IS TO BE USED TO ACQUIRE CONSENTS FROM THOSE APPROPRIATORS WHO COULD POSSIBLY BE AFFECTED BY THE GRANTING OF A PETITION BY THE STATE BOARD OF CONTROL. THE FORMAT MAY VARY ACCORDING TO THE TYPE OF PETITION. WHENEVER CONSENTS ACCOMPANY A PETITION, EVIDENCE OF OWNERSHIP FOR THE PERSONS GIVING CONSENT MUST BE PROVIDED, IF CONSENTING DIVERSION IS NOT LEGALLY ORGANIZED.
_____________________________________________________
CONSENT TO PETITION FOR CHANGE OF POINT OF DIVERSION AND MEANS OF CONVEYANCE
The following individuals are all the owners of record of those appropriations under the Unnamed Ditch, diverting from No Name Creek. Each of the following individuals has read, understands, and gives their consent to the petition of John Doe for change of point of diversion and means of conveyance for the J. W. Doe Appropriation, Permit No. 3214, Proof No. 1491, for 62.0 acres, to be changed from the No Name Ditch to the Unnamed Ditch. Unless this petition is amended, the undersigned also hereby waives any further notice requirement.
(Signed) ____________________________________
The foregoing instrument was acknowledged before me this day of ________________, 20_______. Witness my hand and official seal.
__________________
Notarial Officer
My commission expires:________________________
(Signed)_____________________________________
The foregoing instrument was acknowledged before me this day of ________________, 20_______. Witness my hand and official seal.
____________
Notarial Officer
My commission expires:________________________
AUTHORIZATION TO DETACH WATER RIGHTS FOR
CHANGE OF USE OR PLACE OF USE
AND
PETITION FOR VOLUNTARY ABANDONMENT OF WATER RIGHTS FORM
I/We____________________________, of _____________________________,
(Name of Grantor) (Street Address, P.O. Box No. etc.)
City of_________ , County of______________ ,
State of____________ ,
as owner(s) of the following described lands, hereby authorize detachment or abandonment by:
____________________________, of __________________________________,
(Name of Grantee) (Street Address, P.O. Box No. etc.)
City of_____________ , County of__________ ,
State of___________ ,
of the______________ appropriation,
(Appropriation Name)
diverting from________________ , through the______________ ,
(Source) (Ditch or Pipeline)
Permit No.__________ , Priority date of__________________,
for irrigation of the following described lands:
T .___________N. , R. ______________W .
Section_______ :________1/4________1/4 acres
Section_______:_________1/4________1/4 acres
This Authorization allows Grantee or his assignee to petition the State Board of Control for change of use or place of use of the above described water rights attaching to the above described lands as provided for in Section 41-3-104, W.S. 19 77, within five (5) years of the date of the acceptance of this Authorization, and petitions that any or all of the water rights not so changed be declared voluntarily abandoned.
Recent historical use, generally the five (5) years previous to the signing of the Authorization, and other requirements will be needed to support a petition and map to change the use or place of use. If the water rights are to remain in or are being placed in a subdivision, a Water Distribution Plan will also be required. Until such change or voluntary abandonment is granted by the Board of Control, the water rights involved in this Authorization and Petition remain attached for the permitted use on the lands described thereon. Notice to successor owners of these lands that this water right will be removed or abandoned after five (5) years is the responsibility of Grantor or Grantor's successors.
Grantor and Grantee hereby waive any and all notices which may be required by law, including those required in condemnation proceedings provided by Section 41-3-103, W.S. 1977, as amended, and state that neither Grantor nor Grantor's successors or assigns shall, at any time in the future, file any adverse claims or institute any proceedings in law or equity attacking adversely, or in any manner whatsoever, the equities, right, title or interest of any of the water rights herein referred to and for which it is hereby agreed that Grantor has received full and adequate compensation.
GRANTOR AND GRANTEE UNDERSTAND AND AGREE THAT IF NO PETITION FOR CHANGE OF USE OR CHANGE OF PLACE OF USE FOR ALL OF THE WATER RIGHTS ATTACHING TO THE ABOVE DESCRIBED LANDS IS RECEIVED WITHIN THE FIVE (5) YEAR PERIOD AND SUCH PETITION SUBSEQUENTLY GRANTED BY THE BOARD OF CONTROL, GRANTOR AND GRANTEE HEREBY REQUEST THAT THE BOARD OF CONTROL ISSUE A PROPER ORDER DECLARING ALL OF THE REMAINING WATER RIGHTS ATTACHED TO THE ABOVE DESCRIBED LANDS ABANDONED.
An unaltered Authorization and Petition Form shall be completed and submitted for acceptance, along with evidence of lands ownership, recording fees, and a map certified by a professional engineer or land surveyor licensed to practice in Wyoming delineating the above lands, to the State Board of Control, Herschler Building, 4th Floor East, Cheyenne, Wyoming, 82002.
________________________(Signed)
___________________________(Grantor) The foregoing instrument was acknowledged before me this day ____________, of 20___________
Witness my hand and official seal
______________________
Notarial Officer
My commission expires:_____________________
___________________________________________(Signed)
____________________________________________(Grantee)
The foregoing instrument was acknowledged before me this day
____________, of 20___________ Witness my hand and official seal
____________________
Notarial Officer
My commission expires:_________________
_________________________________________________
For Office Use Only
_______________ ______________
DATE APPROVED ADJUDICATION OFFICER
APPLICATION FOR TEMPORARY CHANGE IN POINT OF DIVERSION
DATE: _______________________________________________
Name of Applicant: _______________________________________________________________________
Address: _________________________________________________________________________________
Name of Facility: ___________________________ Source: ___________________________________
Permit No.: _________________________________ Priority Date: ____________________________
Name of Appropriation: ______________________Acres under Change____________ CFS___________
Present Point of Diversion: __________1/4_______1/4, Sec. _______, T. __________, R. __________
Proposed Point of Diversion: _________1/4_______1/4, Sec. _______, T. __________, R. __________
Type of Change requested: ________________________________________________________________
Reason for Change: _______________________________________________________________________
Consents for intervening Points of Diversion, if necessary (may be continued on reverse side):
Facility Signature
_____________________ ___________________________
_____________________ ___________________________
_____________________ ___________________________
_____________________ ___________________________
Intervening Sources:______________________________________________________________________
The following conditions will apply if this request is granted:
A. This irrigation POD change is for _________ water year only, or one year for other uses .
B. There can be no injury to any other appropriators as a result of this change.
C. To acquire permission for a permanent change in Point of Diversion, a Petition must be submitted to the Board of Control (or State Engineer if water right is unadjudicated).
D. The granting of this temporary change in no way commits the Board of Control or State Engineer to approve petition for a permanent change.
E. The granting of this temporary change does not constitute the granting of right-away.
F. This temporary change may be revoked at any time by the Water Commissioner.
___________________________________
Signature of Applicant (if available)
Request for TEMPORARY CHANGE IN POINT OF DIVERSION ______________________________________
(granted/denied)
this ___ day of _______________, 2_____, for the irrigation season of ______________ only.
__________________________________________
SUPERINTENDENT WATER DIVISION
TEMPORARY CHANGE IN POINT OF DIVERSION. The division superintendents are authorized to use temporary changes in point of diversion (separate form for changes of location for ground water wells) up to a maximum of one water year. The affected water right must be a valid appropriation. Approval for a temporary change shall not be given if there is a likelihood of injury to any other appropriator. In no case shall an increase in water use (diversion rate, acres irrigated, area(s) or point (s) of use) by a temporary change be allowed. The superintendents shall forward copies of all temporary change requests and approvals to the State Engineer's and Board of Control's offices in Cheyenne.
If a permanent change is to be requested, a proper petition must be filed with the Board during the period of temporary change. The giving of an approval for a temporary change does not in any way guarantee that the State Board of Control will approve a permanent change.
A request for a temporary change must be made on the form and must be approved in writing by the appropriate superintendent prior to making the change. (SEE FORM ON REVERSE SIDE).
The Superintendent, under W.S. W.S. W.S. 41-3-503 through W.S. W.S. W.S. 41-3-506, may allow temporary changes in certain instances where necessary for equal and fair distribution of water and administration of priorities.
APPLICATION FOR
TEMPORARY CHANGE IN LOCATION OF WELL
DATE: ____________________________________
Name of Applicant: ___________________________________________________________
Address: _____________________________________________________________________
Name of Well: ________________________________________________________________
Permit No.: ________________________ Priority Date: __________________________
Present Location of Well: 1/4_____1/4 Sec. ____, T. _______, R. _______
Proposed Location of Well: 1/4_____1/4 Sec. ____, T. _______, R. _______
(The proposed relocated well will be approximately ____________ feet ____________ (direction)of the existing well.)
Is this well located within a Ground Water Control Area? _________
Total Depth of existing well: ____________ feet
Proposed Depth of relocated well: ______________ feet
Reason for Change:
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
I understand that the following conditions will apply if this request is granted:
A. This change is for the water year ________ only.
B. There can be no injury to any other appropriators as a result of this change.
C. To acquire permission for a permanent change in the location of this well, I must submit a Petition to the Board of Control.
D. The granting of this temporary change in no way commits the Board of Control or State Engineer to approve the petition for a permanent change.
________________________
Signature of applicant
Request for TEMPORARY CHANGE IN LOCATION OF WELL _____________________________
(granted/denied)
this_____________ day of_______________ , 2__________ , for the irrigation season of only.
_______________________________________
SUPERINTENDENT WATER DIVISION ______
TEMPORARY CHANGE IN WELL LOCATION. The division superintendents are authorized to use temporary changes of location for ground water wells for short periods of time (up to a maximum of one year). The affected ground water right must be a valid appropriation. If a well is involved which is located in a ground water control area, the superintendent may approve the temporary change; however, he should consult with the Administrator of the State Engineer's Ground Water Division prior to acting on the request. (Recommendation of the Control Area Advisory Board will be required prior to approving a permanent change in well location). Approval for a temporary change shall not be given if there is a likelihood of injury to any other appropriator. In no case shall an increase in water use (yield, acres irrigated, area(s) or point(s) of use) by a temporary change be allowed. The superintendents shall forward copies of all temporary change requests and approvals to the State Engineer' s and Board of Control Offices in Cheyenne.
If a permanent change is to be requested, a proper petition must be filed with the Board during the period of temporary change. The giving of an approval for a temporary change does not in any way guarantee that the State Board of Control will approve a permanent change.
A request for a temporary change must be made on the form and must be approved in writing by the appropriate superintendent prior to making the change. (SEE FORM ON REVERSE SIDE.)
The Superintendent, under W.S. W.S. W.S. 41-3-503 through W.S. W.S. W.S. 41-3-506, may allow temporary changes in certain instances where necessary for equal and fair distribution of water and administration of priorities.
IMPORTANT NOTICE TO APPROPRIATORS
The following condition must be met if a rotation is to be allowed:
1. All appropriations involved must be in priority and entitled to water during the entire rotation period;
2. An actual rotation of water use for the lands under each appropriation is required, and each rotation period will not exceed ten days unless a longer period is agreed to by the hydrographer commissioner or water commissioner;
3. The proposed rotation shall not result in injury to other appropriators;
4. The rotation proposed is limited to one season.
NOTICE OF INTENTION TO ROTATE
To: ________________________________ Date: _________________, 2______.
District No. _____, Division No. _________
______________________________, Wyoming
In accordance with W.S. W.S. W.S. 41-3-612, you are hereby notified that the undersigned wish to rotate the following water appropriations in the manner and for the time outlined below:
1. Name of Source Amount of
Ditch or Supply Appropriation Priority Owner
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
2. Rotation will be commenced on__________,_____ 2____ , and will be accomplished as follows: __________________________________________________
__________________________________________________________
__________________________________________________________
DO NOT WRITE IN SPACE BELOW - FOR HYDROGRAPHER COMMISSIONER OR WATER COMMISSIONER ONLY
Received on________ ,2________ . By__________________
District No._________ Division No._______________
Remarks:______________________________________________________________________
__________________________________________________________
Approved this________ day of____________ , 2_______ .
______________________________
District No. _____ Division No. ____
A GENERAL REQUIREMENT FOR REQUESTING REGULATION IS THE MAINTENANCE OF A SATISFACTORY HEADGATE AND MEASURING DEVICE AT THE LEGALLY-RECORDED DIVERSION POINT SO AS TO ENABLE THE HYDROGRAPHER COMMISSIONER OR WATER COMMISSIONER TO DETERMINE IF THE REQUEST FOR REGULATION HAS BEEN SATISFIED. IF YOU DO NOT HAVE AN APPROVED HEADGATE AND MEASURING DEVICE PRESENTLY INSTALLED, YOUR REQUEST FOR REGULATION WILL BE SUBJECT TO REVIEW BY THE HYDROGRAPHER COMMISSIONER OR WATER COMMISSIONER AND/OR DIVISION SUPERINTENDENT.
THE APPROPRIATOR IS OBLIGATED TO NOTIFY THE HYDROGRAPHER COMMISSIONER OR WATER COMMISSIONER PRIOR TO THE DATE WHEN WATER WILL NO LONGER BE USED SO THAT PROPER ADJUSTMENTS MAY BE MADE TO AVOID THE WASTE OF WATER.
________________________________________________________
REQUEST FOR REGULATION
Pursuant to W.S. W.S. 41-3-603, 41-3-604, 41-3-606, 41-3-304 and 41-3-111 revised statutes 1977, I hereby request regulation of _________________
________________________________________________________
and tributaries and this requested to supply my (our) appropriation of water through the _____________________________________________________
Ditch(es) or Reservoir(s) under Permit Nos. ___________________________ , _____________________________________with priority(s) of_____________________________ until___________________________________
Signed:_________________ __________________
________________ _____________________
________________ _____________________
Received on____________________ , 2________________ .
_________________________________________________
Hydrographer Commissioner or Water Commissioner District No. _________, Division No. _____
Request approved: ___________
Request denied: ___________
Comments:________________________________________
_________________________________________________
THE FOLLOWING IS A SAMPLE OF A PETITION WHICH CAN BE USED TO FACILITATE RECORDATION OF A CHANGE OF POINT OF DIVERSION AND MEANS OF CONVEYANCE THAT OCCURRED PRIOR TO 1965.
PETITION FOR RECORDATION OF A )
CHANGE OF POINT OF DIVERSION )
AND MEANS OF CONVEYANCE PRIOR )
TO 1965 OF THE J. W. DOE )
APPROPRIATION, PERMIT NO. ) BEFORE THE
3214, DIVERTING FROM NO NAME ) STATE BOARD OF CONTROL
CREEK, TRIBUTARY NO NAME ) CHEYENNE, WYOMING
RIVER, THROUGH THE NO NAME )
DITCH, WITH PRIORITY OF MAY )
16, 1905, CHANGED TO THE )
UNNAMED DITCH. )
O.R. 2, P. 446; C.R. 3, P. 435; PROOF NO. 3491
STATE OF WYOMING )
) SS
COUNTY OF FREMONT )
COMES NOW John Doe of Box 00, Split Rock, County of Fremont, State of Wyoming, who being duly sworn on oath according to law does hereby make the following statement of facts and petition:
1. THAT he is the owner of the lands and the appropriation for which a recordation of a change of point of diversion and means of conveyance prior to 1965 is sought, as evidenced by the attached proof of ownership from the County Clerk of Fremont County, Wyoming.
2. THAT the appropriation for which a recordation of a change of point of diversion and means of conveyance prior to 1965 is sought is the J. W. Doe Appropriation, Permit No. 3214, adjudicated under Proof No. 3491, in the amount of 0.89 c.f.s. for the irrigation of 62.0 acres, diverting from No Name Creek, tributary No Name River, through the No Name Ditch (as of record), with priority of May 16, 1905, and of record in Order Record 2, page 446; Certificate Record 3, page 435 describing the lands irrigated as follows:
| Township 30 North, Range 98 West | |
| Section 19: SW1/4SW1/4 | 32.0 acres |
| SE1/4SW1/4 | 10.0 |
| Section 30: NW1/4NW1/4 | 20.0 |
| Total | 62.0 acres (0.89 c.f.s.) |
3. THAT your petitioner requests a recordation of a change of point of diversion and means of conveyance prior to 1965 of the J. W. Doe Appropriation, Permit No. 3214, which diverts from No Name Creek through the No Name Ditch (as of record), at a point described as North 12° 30' East, 1620.0 feet distant from the Southwest Corner of Section 28, Township 30 North, Range 99 West, and situated in the SE1/4SW1/4 of Section 28, to the Unnamed Ditch, diverting from the same source of supply, under Permit No. 3400, approximately 1/2 mile downstream at a point described as North 15° 20' East, 1056.0 feet distant from the Southwest Corner of Section 28, Township 30 North, Range 99 West, and situated in the SW1/4SW1/4 of Section 28.
The lands for which this recordation is requested are described as follows:
| Township 30 North, Range 98 West | |
| Section 19: SW1/4SW1/4 | 32.0 acres |
| SE1/4SW1/4 | 10.0 |
| Section 30: NW1/4NW1/4 | 20.0 |
| Total | 62.0 acres (0.89 c.f.s.) |
4. THAT the reason for the requested recordation is that a portion of the No Name Ditch was subject to washouts and had been difficult to maintain. The change of point of diversion and means of conveyance to the Unnamed Ditch has eliminated this problem and provide a more economical means of conveyance. The petitioner has evidence that this change occurred in 1952 or 1953, and proof that this change occurred at that time accompanies the petition.
5. THAT a map does not accompany this petition, since the new point of diversion has a current and accurate legal survey tie, to a known corner of the public land survey, on file in the State Engineer's Office and/or the State Board of Control, and because the entire appropriation(s) or all permitted acreage within the involved quarter-quarters under this facility has been included in this request.
6. THAT the appropriation involved has been diverted at least once in the last five years when water was available through the new point of diversion and means of conveyance.
7. THAT the granting of this petition has not injured any other appropriators. It is the prayer of your petitioner that this petition for recordation of a change of point of diversion and means of conveyance prior to 1965, as outlined in paragraph 3 above, be allowed without loss of priority, and that a proper Order of the Board be entered recording same.
Respectfully submitted,
___________________
John Doe
The foregoing instrument was acknowledged before me this ___
day of __________________, 20______.
Witness my hand and official seal.
______________________________
Notarial Officer
My Commission expires: _____________________________________
Effective 10/29/2012