Subsurface Memorandum of Surrender

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Indian Oil and Gas Canada

(Section 44 - Indian Oil and Gas Regulations, 1995)

Memorandum of Surrender

to the Government of Canada

IN THE MATTER OF Oil and Gas [Lease or Permit] No.
[OL-____, TL-____, FL-____, CL-____ or OP-____] dated
[date] ("Contract") covering the lands therein described.

The undersigned, as [Lessee or Grantee], in the said Contract, hereby for good and sufficient consideration, unconditionally releases, surrenders and quitclaims unto the Government of Canada, all its right, title, estate and interest in the Contract.

This surrender is effective as of this _______ day of ____________________, 200 ___ ("Effective Date").

IN WITNESS WHEREOF [Corporate Name] has caused these presents to be executed, this _______ day of ____________________, 200 ___.

ACKNOWLEDGED AS OF THE EFFECTIVE DATE.

NOTE

- Four originals of the Memorandum of Surrender must be submitted for approval.

- Lessee/Grantee shall affix its corporate seal or the signature shall be witnessed by at least one person who is not a party to the Contract, and the attached affidavit of witness completed before a notary public. If executed by power of attorney, Lessee/Grantee shall also provide original power of attorney documentation to Indian Oil and Gas Canada, if not previously provided.

- No fee is applicable.

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Affidavit of Witness

re: Execution (Signing) of Document

Canada Province of ______________

I ________________________________

of the City of ______________________

of the Province of ___________________

to Wit

Make Oath and Say

1. That I was personally present and did see the attached instrument duly executed by __________________________________________.

2. That I know the said party(ies), and that the said party(ies) in my belief is/are the full age of majority for the Province of _______________.

3. That I am the subscribing witness to the said instrument.

Signature of Witness __________________________________________.

SWORN before me at the City of _______________, Province of _______________,

this _______________ day of _______________, ___________.

__________________________________________.

A Notary Public or a Commissioner for taking Oaths, in and for the Province of _______________.

My commission expires: _______________.