Free Application must be complete where applicable - Colorado

GWS-75 (01/2005)

STATEMENT AND REQUEST TO CANCEL A DETERMINATION OF WATER RIGHT COLORADO GROUND WATER COMMISSION Room 818 Centennial Building, 1313 Sherman Street Denver, CO 80203

Form must be complete where applicable. Type or print in BLACK INK. No overstrikes or erasures unless initialed.

Note: This form may only be used for a Determination of Water Right, in the Dawson, Denver, Arapahoe, or LaramieFox Hills aquifer, that was approved by the Colorado Ground Water Commission pursuant to CRS 37-90-107(7).

I (we), an allocation of groundwater in the consisting of acres, located in

, claim and say that I (we) have , aquifer, for an overlying land area County.

complete control of the water right described as Determination of Water Right Number

Having complete control of the above-described water right, I (we) hereby request that this determination of water right and allocation of ground water be permanently canceled and abandoned. I (we) hereby affirm that I (we) have read and understand the above statement and the information I (we) have provided is true and correct.

Signed and dated this ____________ day of _______________________________, 20____________.

Signature(s):

(Please Print the Following)

Signer(s) Name & Title:________________________________________________________________ Mailing Address: City, State & Zip: Telephone No.: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________