Free Applicant Name - Kansas

Addition to Exemption KSA 79-201g Page 1 of 1

Applicant Name: ________________________ Docket No. _____________________________

Addition to Exemption Application Watershed Dam or Reservoir K.S.A. 79-201g
1. Provide a complete copy of the Certificate of Completion of Dam and all attachments from the Division of Water Resources. Provide the legal description(s) of the real property owned by you which is contiguous to and a part of the same tract of land upon which the dam or reservoir has been constructed.

2.

VERIFICATION

I, ________________________________, do solemnly swear or affirm that the information set forth herein is true and correct, to the best of my knowledge and belief. So help me God. _____________________________________ Signature of Applicant

_____________________________________ Printed Name and Title State of ____________________ County of __________________ ) )

This instrument was acknowledged before me on __________ by ______________________________.

Seal

_____________________________________ Signature of Notary Public

My appointment expires: ________________

Revised 5/07