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.