The undersigned represents that he/she is the owner of the property identified by the address herein (“Real Property”) and/or is authorized to execute this form and make the representations and warranties set forth herein for themselves and on behalf of any tenants or other party responsible for the maintenance or operation of any underground, buried or concealed utilities, structures, facilities, objects or hazards (collectively “Buried Facilities”) or any other parties who have an interest in the Real Property (individually and collectively “Property Owner”). Property Owner represents and warrants that all Buried Facilities on the Real Property have been located and are clearly marked and identified on the Real Property. Property Owner further represents and warrants that this form has been properly and accurately completed with respect to identification of Buried Facilities on the Real Property and that Northern Indiana Public Service Company (“NIPSCO”) has a right to rely upon the information provided by Property Owner on this form. Further, in exchange for NIPSCO performing the work set forth below, the Property Owner hereby releases, waives and agrees to hold harmless NIPSCO, its agents and employees, from any and all liability, claims, causes of actions, demands or damage brought by any party relating to any damage to any Buried Facilities arising from or caused by NIPSCO’s performance of the work regardless of whether such Buried Facilities are marked or unmarked on the Real Property or whether properly identified on this form.