SV 1 
                                                                                                            Rev. 11/13 

                   P.O. Box 530 
                   Columbus, OH  43216-0530 
                                Application for Severer’s License
                                To Sever Natural Resources in Ohio
Please list one permit number obtained from the Ohio Department of Natural Resources (ODNR) 
If such permit, license, owner number, etc., was not obtained, please contact ODNR at 614-265-6922 for oil and gas or 614-
265-6633 for all other minerals so that your application can be processed.

 Name                                                                         FEIN 

 DBA                                                                          Social Security number 

 Street                                                                       Telephone number 
  
 City                                            State   ZIP code             Fax number 
    
When did or when will you start operating?
                                                         Month                                 Year
Locations in Ohio where severing activities occur – county, township, section, quarter and/or lot number 

Incorporation date                                       Country 

State                                                    Fiscal year end 

Check whether severer operates as:    F     Sole owner F Partnership  F Fiduciary    F Association F LLC 
F LLP   F     Corporation 

Corporate charter number                                 NAICS code 

List below the titles, names, phone numbers and e-mail addresses of contacts. 

        Title                               Name                              Phone number / E-mail address 

Check resources to be severed:  F Coal      F Salt     F Limestone  F Dolomite F Sand         F Gravel   F Oil 
F Gas   F Clay     F Sandstone/Conglomerate      F Shale F Gypsum         F Quartzite 
I hereby declare the above to be true and correct to the best of my knowledge and belief. 

                      Date                                                Signature of severer or agent 
All questions on this application are to be answered. This license, when acknowledged, shall continue valid until surrendered by 
the severer or canceled for cause by the tax commissioner. THIS IS NOT AN ANNUAL LICENSE AND WILL NOT REQUIRE A  
RENEWAL. Forward severer’s application to the Ohio Department of Taxation, Excise Tax Section, P.O. Box 530, Columbus, 
OH 43216-0530. If you have any questions, please call (855) 466-3921.