Form 4430

OMB Control Number 1010-0120
Expiration Date: XXXXXXXXXX

Solid Minerals Production and Royalty Report

Mine Information
Mine Name:
Basic Unit
Federal/Indian Indicator:
(Circle one grouping)

Federal/State/Fee
or
Indian/State/Fee

Report Type
(Circle one grouping)

Original P & R/Other Obligation/P & R Value Adjustment
or
P & R Volume/Value Adjustment

The Paperwork Reduction Act of 1995 requires us to inform you that the Office of Natural Resources Revenue (ONRR) is collecting this information
from all Federal and Indian solid mineral lessees. The ONRR is collecting this information to improve its ability to verify that revenue due the
Government has been paid correctly under applicable laws, regulations, and lease terms. We estimate the burden is 30 minutes per report per
month reporting electronically. Comments on the accuracy of this burden estimate or suggestions on reducing this burden should be directed
to the Information Collection Clearance Officer, MS 5438, 1849 C Street, N.W., Washington, DC 20240. Proprietary information is protected by
the Federal Oil and Gas Royalty Management Act of 1982 (30 U.S.C. 1733), the Freedom of Information Act (5 U.S.C. 552 (b) (4), the Indian
Minerals Development Act of 1982 (25 U.S.C. 2103) and Department regulations (43 CFR 2). An agency may not conduct or sponsor, and a person
is not required to respond to, a collection of information unless it displays a currently valid OMB Control Number.

Form MMS-4430

OMB Control Number 1010-0120
Expiration Date: XXXXXXXXXX

Original Summary Page

P & R Original Summary
Sales Month/Year:

Sales Point

Product

Total:

Form MMS-4430

Units Produced Units Sold

Gross Proceeds Total Allowed Cost
$
$
$
$
$
$

Royalty Payment
$
$
$
$
$
$

OMB Control Number 1010-0120
Expiration Date: XXXXXXXXXX

Original Detail Page

Mine Name

Business Unit

P & R Original
Total Units Sold:

Lease Number:

Ending Inventory:

Form MMS-4430

Sales Point

Product

Total Units Transferred:

Total Gross Proceeds: $
Total Allowed
Processing:
$

Beginning Inventory:

Sales Month/Year

Total Allowed
Transportation Cost:

$

Royalty Rate/Fixed Rate:

%

Inventory/Volume
Adjustment:

Units Produced:

Gross Proceeds:
$

Allowed Transportation
Allowed Processing Cost:
Cost:
$
$

Production Available for Sale:

Land Class: (Circle)
Indian State Fee

Federal

Units Transferred:

Units Sold:

Royalty Before
Allowance:
$

Royalty
Payment:
$

OMB Control Number 1010-0120
Expiration Date: XXXXXXXXXX

Other Obligations Page

Mine Name

Business Unit

Other Obligations

Sales Month/Year
January February
March April May June

Total :

Form MMS-4430

Lease Number

Payment Type

Interest Bearing
Indicator
Yes or No?

Interest From Date
Payment Amount
January February
$
March April May June

$

OMB Control Number 1010-0120
Expiration Date: XXXXXXXXXX

Value Adjustment Page

Mine Name

P & R Adjustment
Interest Bearing Indicator:
Interest From Date:
MMS Initiated:
Allocate New Values
Total Gross Proceeds
Difference:
Total Allowed
Transportation Cost
Difference:

Sales Month/Year

Sales Point

Total Allowed Processing Cost
Difference:

$

Yes or No
Customer Initiated:

$

$

Lease Number:
Gross Proceeds:
Allowed Transportation
Cost:

$

Allowed Processing Cost:

$

Comments for above lease:

Form MMS-4430

Business Unit

Current Values
$

Royalty Rate/Fixed Rate: %
Gross Proceeds Difference:
Allowed Transportation Cost
Difference:
Allowed Processing Cost
Difference:
Royalty Payment:

Value
Differences
$
$
$
$

OMB Control Number 1010-0120
Expiration Date: XXXXXXXXXX

Value/Volume Adjustment Summary Page

Mine Name

Business Unit

Sales Point

Sales Month/Year

Completed?

Royalty Payment

Total:

Form MMS-4430

$
$

Product

Value/Volume Adjustment Detail Page

Mine Name

Business Unit

P & R Adjustment
Interest Bearing Indicator:
Interest From Date:

Sales Month/Year

OMB Control Number 1010-0120
Expiration Date: XXXXXXXXXX

Sales Point

Product

Yes or No

MMS Initiated or Payor Initiated?
Allocate New Values
Total Units Sold Difference:

Total Units Transferred
Total Allowed Transportation
Cost Difference:
$

Total Gross Proceeds Difference: $
Total Allowed Processing Cost
Difference:
$

Lease Number:

Current Values

Computed Differences

User Entered Differences

Beginning Inventory:

Total Difference

N/A
N/A

Units Produced:
Transferred Units:
Inventory Before Sales:
Units Sold:

N/A

Allowed Transportation Cost:

$

N/A

$

$

Allowed Processing Cost:

$

N/A

$

$

Gross Proceeds:

$

$

$

$

Ending Inventory:
Royalty Rate/Fixed Rate:
Comments for the above lease:
Form MMS-4430

N/A
%

Royalty Payment:

$

OMB Control Number 1010-0120
Expiration Date: XXXXXXXXXX

Confirmation Page

Mine Name

Business Unit

Sales Month/Year

Your submission will be manually processed.
Main Payment Confirmation
Customer Number:
Customer Document ID:
Payment Method:
Federal/Indian Indicator:
Production & Royalty Total:
Value Adjustment Total:
Other Obligation Total:
Sub Total:
Credit 1 Amount:
Credit 1 Doc ID:
Credit 2 Amount:
Credit 2 Doc ID:
Credit 3 Amount:
Credit 3 Doc ID:
Grand Total:

Form MMS-4430

$
$
$
$
$
$
$
$