M-950RFO (5-04)
RELEASE OF FEE OWNER
Permit Application No.
COUNTY
CITY-BORO-TWP.
S.R.-SEG.-OFF.
APPLICATION No.
PERMIT No.
PERMITTEE
Name
Address
THIS RELEASE, made this ____ day of ________________, 200__, by
fee owner(s) of property over which the above referenced-permittee has applied for a highway occupancy
permit, ____ heirs, executors, administrators, successors and/or assigns, hereinafter, whether singular or
plural, called the OWNER.
WHEREAS, the permittee referenced above has applied to the Commonwealth of Pennsylvania,
Department of Transportation, called the Department, for a permit to construct a driveway to the above
mentioned State highway over property owned by OWNER; and
WHEREAS, the permittee has the following estate or interest in the area owned by OWNER over
which the driveway will be located:
___
___
___
___
___
___
Easement (copy attached)
License (copy attached)
Right of access due to subsurface rights (copy attached)
Agreement of Sale (copy attached)
Option to Purchase (copy attached)
Other (copy attached); and
WHEREAS, the OWNER has agreed with the permittee to grant this release to the Department to
allow the permit to be issued to the permittee.
NOW, THEREFORE, the OWNER does hereby remise, release, quitclaim and forever discharge the
Department, its agents, employees and representatives of and from all suits, damages, claims and demands of
any type whatsoever arising against it as a result of granting the permit to permittee.
IN WITNESS WHEREOF, the OWNER has executed or caused to be executed these presents, intending to be
legally bound thereby.
Witness ______________________________________
(SEAL) ___________________________________
Witness ______________________________________
I attest to the signature of the officer who has
executed this deed and certify that execution
thereof has been duly authorized, by the
(SEAL) ___________________________________
Corporation, Partnership, Association, Club, etc.
BD. OF DIRS., MAJORITY VOTE OF ASSOC., ETC.
BY ____________________________________
President
BY
Secretary
INDIVIDUAL(S), ASSOCIATION, CLUB, etc.
COMMONWEALTH OF PENNSYLVANIA :
:
COUNTY OF
:
CORPORATION
ss:
On
, before me, the
undersigned Officer, personally appeared
COMMONWEALTH OF PENNSYLVANIA :
:
COUNTY OF
:
ss:
On
, before me, the
undersigned Officer, personally appeared
to be the
, who acknowledged himself
of
known to me (or satisfactorily proven) to be the
person(s) whose name(s)
subscribed to the
within instrument, and acknowledged that
executed the
same.
a corporation, and that he as such officer, being authorized to
do so, executed the foregoing instrument on behalf of the said
corporation.
IN WITNESS WHEREOF, I have hereunto set my hand
and official seal.
IN WITNESS WHEREOF, I have hereunto set my hand
and official seal.
(SEAL)
(SEAL)
Notary Public
My Commission Expires:
COMMONWEALTH OF PENNSYLVANIA :
: ss:
COUNTY OF
:
Recorded in the Office for Recording of Deeds in and for
aforesaid County in Deedbook
Page
Witness my hand and seal of Office on
Notary Public
My Commission Expires:
I certify that, upon recording, the withing instrument should be
mailed to:
Right-of-Way Administrator
Pennsylvania Department of Transportation