Form MMS-4411 Safety Net Report

OMB Control Number 1012-0002
OMB Approval Expires 08/31/2012

U.S. Department of the Interior
Office of Natural Resources Revenue

SAFETY NET REPORT
Form MMS-4411
PAYOR'S NAME___________________________________________________
ADDRESS________________________________________________________
CITY/STATE__________________________________________ZIP__________
PAYOR CODE
| | | | | |
REVIEW PERIOD:__________________________________________________
NAME OF INDEX ZONE:_____________________________________________
INDEX PRICING POINT:_____________________________________________

YEAR

MONTH

SAFETY NET PRICE
(volume weighted average
price per MMBtu)

INDEX VALUE
($/MMBtu)

SAFETY NET
DIFFERENTIAL*
($/MMBtu)

January
February
March
April
May
June
July
August
September
October
November
December

*Please refer to 30 CFR 1206.172(e)(4)(i) for instructions on how to calculate the safety net differential.
Prepared By: _____________________ Phone No. ____________ Date _________
Paperwork Reduction Act of 1995 (PRA) Statement: The PRA (44 U.S.C. 3501 et seq.) requires us to inform you that we collect
this information to ensure that Indian mineral lessors receive the maximum revenues from mineral resources on their land consistent
with the Secretary’s trust responsibility. ONRR uses the information to aid in its compliance efforts. Responses are mandatory
(30 CFR 1206.172). Proprietary information is protected in accordance with standards established 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)), and the 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. Public reporting burden for this form is estimated to average
3 hours per response, including the time for reviewing instructions, gathering and maintaining data, and completing and reviewing
the form. Direct comments regarding the burden estimate or any other aspect of this form to the Officer of Natural Resources
Revenue, Attention: Rules & Regs Team, P.O. Box 25165, Denver, CO 80225-0165.

Form MMS-4411 (revised 3/2012)

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