Dam Owner Change of Ownership

ds-04 03/08 OSE File Number:

NEW MEXICO OFFICE OF THE STATE ENGINEER

CHANGE OF OWNERSHIP OF A DAM

1. OWNER OF RECORD OF DAM

Name: Work Phone:

Title: Home Phone:

Address:

City: State: Zip:

NEW OWNER

Name: Work Phone:

Title: Home Phone:

Address:

City: State: Zip:

2. NEW OWNER CERTIFICATION

State of )

) ss.

County of )

I, being first duly sworn, upon my oath, state that I am the owner of Dam; I acknowledge that this Dam is under the jurisdiction of the State Engineer; I acknowledge the responsibility and liability of dam ownership; and all that is shown hereon is done with my free consent and in accordance with my wishes and state that the same are true to the best of my knowledge and belief.

______

Dam Owner’s Signature Date

Subscribed and sworn to before me this ______day of ______, 20___.

______

Notary Public

My commission expires ______(SEAL)

3. ACTION OF STATE ENGINEER

This Change of Ownership form is hereby accepted for filing. The acceptance by the State Engineer Office does not constitute validations of the right conveyed.

______

Office of the State Engineer Date

03/05 OSE File Number:

NEW MEXICO OFFICE OF THE STATE ENGINEER

CHANGE OF OWNERSHIP OF A DAM

FOR CORPORATIONS OR POLITICAL SUBDIVISIONS

1. OWNER OF RECORD OF DAM

Name: Work Phone:

Title: Home Phone:

Address:

City: State: Zip:

NEW OWNER

Name: Work Phone:

Title: Home Phone:

Address:

City: State: Zip:

2. NEW OWNER CERTIFICATION

State of )

) ss.

County of )

I, , being first duly sworn, upon my oath, state that I am the of the , a duly organized under the laws of the State of , that the is the owner of Dam, and that, on their behalf, I acknowledge that this Dam is under the jurisdiction of the State Engineer; I acknowledge the responsibility and liability of dam ownership; and all that is shown hereon is done with their free consent and in accordance with their wishes and state that the same are true to the best of my knowledge and belief.

______

Representative’s Signature Date

Subscribed and sworn to before me this ______day of ______, 20___.

______

Notary Public

My commission expires ______(SEAL)

3. ACTION OF STATE ENGINEER

This Change of Ownership form is hereby accepted for filing. The acceptance by the State Engineer Office does not constitute validations of the right conveyed.

______

Office of the State Engineer Date

NEW MEXICO OFFICE OF THE STATE ENGINEER

CHANGE OF OWNERSHIP OF A DAM

4. INSTRUCTIONS

This form shall be filed with original signatures and filing fee of $5.00.

Hit “F1” key for additional instructions for each cell. Cell sizes are limited.

The Form shall be mailed to the attention of the OSE Dam Safety Bureau, P.O. Box 25102, Santa Fe, New Mexico 87504.