PETITION FOR INCLUSION

TO:     THE BOARD OF DIRECTORS OF THE LOWER SOUTH PLATTE WATER CONSERVANCY DISTRICT

I, Petitioner, _________________________ state that I am the fee owner of the following described property or properties:

And state that I desire the above described land(s) be included in said District.

In Compliance with Section 37-45-136, C.R.S., I hereby submit and file this Petition with the Board of Directors of the District and pray that said lands be included in the District.

It is expressly understood and agreed that the costs of the inclusion proceeding consists of a one-time, non-refundable fee of $100.00.  If the costs of legal, engineering, publication and administrative fees are more than the amount deposited, Petitioner will be required to pay any additional costs prior to the granting or denial of the Petition. 

Dated this ____ day of _________________, 2005.

                                                                                                                                                                                                            _______________________________

                                                            Petitioner

STATE OF COLORADO   )

                                                            ) SS.

COUNTY OF LOGAN )

SUBSCRIBED AND SWORN to before me by _______________ this _____ day of _________________, 2005.

            WITNESS my hand and official seal.

            My Commission Expires:

                                                                                    ________________________________

                                                                        Notary Public