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Affirmation of Acreage Control and Rights in Target Formation

Effective August 2, 2005, all applications for well permits subject to Section 23-0501 of the Environmental Conservation Law must include this form. This includes applications to drill, deepen, plug back or convert for oil or gas production outside of pre-1981 oil fields and pre-1995 gas fields which are not being extended.

The applicant should complete Parts 1, 2 and 3 of the form, and submit it together with the application for a well permit. The permit application will not be processed without this form.

The form must be signed by an authorized individual listed in box 7 of the owner's Organizational Report on file with the Division of Mineral Resources as of the date of the application.

This form does not replace the affirmation and acknowledgement on the permit application form itself. The affirmation and acknowledgement on the permit application form must also be completed.

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    Albany NY 12233-6500
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