Class Action Questionnaire

1. Name
2. Maiden Name or Other Names Used:
3. E-mail Address
4. Mailing Address:
5. City:
6. State Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
7. Zip Code
8. County
9. Home Phone No.
10. Work Phone No.
11. Cell Phone No.
12. Fax No.

Are you over 18 years of age?

1. Yes
2. No

Name a nearest relative or friend who we may contact if efforts to reach you are not successful.

1. Name:
2. Mailing Address:
3. City:
4. State Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
5. Zip Code
6. County
7. Home Phone No.
8. Work Phone No.
9. Cell Phone No.
10. Fax No.
11. E-mail Address

Do you own minerals in Texas?

1. Yes
2. No

Were you made an offer to lease your minerals in Texas?

1. Yes
2. No

Was the offering company acting on behalf of Chesapeake?

1. Yes
2. No

Did you sign an oil and gas lease OR other agreement relating to your minerals?

1. Yes
2. No

Did Chesapeake refuse to pay you the amount of money promised?

1. Yes
2. No

1. I have read and understand the disclaimer.