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I I I I I Statement of Verification and Membership Agreement Each participant in the AGUA plan agrees to indemnify, defend, and hold harmless the Arkansas Groundwater Uscrs' Association from any and all liability expenscs, claims, or actions based on that participant's well diversions. I certify that the foregoing information is true and correct to the best of my knowledge. I hereby authorize the power supplier for each well included on tltis form to provide power records to the Division Engineer and AGUA on a monthly basis and to provide power meter and other information about my electrical scrvice as requested by the Division Enginccr. 1 1 I I I 1 I I 1 I I I I I I understand that a loan has been sccured from the Colorado Water Conscrvation Board and an account has been established for repayment. Under the state statute creating the loan account, well users that accept the benefits of the loan must agree to cease pumping should they fail to pay membership dues, including water. I understand that by virtue of my membership in AGU^, I have accepted the benefits of this loan account. I hereby agree to cease pumping water covered by my membership immediately, if I fail to make full payment of my membership dues. I understand that failure to cease pumping under these circumstances may result in prompt and complete curtailment by the State Enginccr of the use of my well(s). I hereby agree to comply with any new rules or amendments to existing rules adopted by the State Engineer and approved by the water court pertaining to the measurement or usc of groundwater on the Arkansas River Basin. I have read the foregoing and agree to abide by its terms and all other reasonable rules and regulations of AGUA. Signature of Owner Date Calculation of 1997 Dues (Must be Received not later than January 15, 1997) Administration No. of wells _ @ $205 each New Member No. of wells _ @ $100 each Well Testing (For wells that must be tested in 1997) Basic Test No. of wells _@ $ 110 each Total: Complex Test No. of wells _@ $135 each Total: Supplemental Plan (only for wells applying AFTER January 15) No.ofwells_@$IOOeach Total: Supplemental Plan (only for wells applying AFTER February 15) No. of wells @ $200 each Total: Inactive Wells No. of wells _ @ $ 50 each Total: Total Due for 1997 Grand Total: Total: Total: Calculation of aqe-feet of Water Needed to Be Augmented for 1997 Pumping Season. We cannot process your application without this information. A bill for your water will be sent after receiving the following information and will be due no later than March 15, 1997 or if after that date, with the application. For an idea of what to order, a copy of last yeam use should have been with this application. # or WELLS ACRES IRRI. CROP ACRE FEET NEEDED FROM THE WELLS Calculation of water dnes = acre feet X $ = $ If you are a new active member, with this application, please send copies of your: Well testes) or the State 3.1 or 3,2 formes). Electric records or the State 6.2 Form(s) or Flow meter readings or the State 6.1 Form(s) Page 4 of 4 4app97 VER 7-14-97. PAGE40F4