Form From 101 From 101 Dry Gas Report

Osage Form 101 OMB Control No. 1076-XXXX

Revised May 2013 Expires: XX/XX/XXX

Meter Station No.

_________________

DRY GAS REPORT

FOR MONTH OF ______________________________________, YEAR:___________

25CFR 226 – Lessee shall furnish certified monthly reports by the 25^th of each month covering all operations, whether there has been production or not.

U.S. DEPARTMENT OF THE INTERIOR

BUREAU OF INDIAN AFFAIRS

OSAGE AGENCY

813 Grandview, P.O. Box 1539

Pawhuska, Oklahoma, 74056

(918) 287-5740 FAX: (918) 287-5786

LESSEE ID NO.:_________

Lessee Name: ________________________________________Current Phone No.:______________________________________

Address:_______________________________________________ City:______________________ State:______ Zip:__________

Gas purchaser:_____________________________________________________ Purpose: Domestic / Sales / Other (CIRCLE ONE)

Location of meter:_________________________________________________ BTU adjustment:___________________________

LEASE DESCRIPTION

Osage Contract Number

¼

SEC

TWP

RGE

Royalty Rate

Type of Gas1

Royalty Amount

MCF

Unit price paid per MCF

Price paid per MMBTU

No. of wells produced

Date last produced MO/DY/YR

¹Use: CHG (CASINGHEAD); NG- NATURAL GAS (GAS WELL GAS); CBM (COALBED METHANE)

²CONSOLIDATED GAS LEASES – PRODUCTION FROM EACH QUARTER SECTION OF CONSOLIDATION MUST BE ACCOUNTED FOR SEPARATELY AND COLUMN IS TO BE TOTALED FOR EACH CONSOLIDATION.

I CERTIFY THAT THE FOREGOING REPORT IS TRUE AND CORRECT.

__________________________________________________________________ __________________________

Signature and Title Telephone Number

Paperwork Reduction Act (PRA) Statement: This information is collected to meet reporting requirements and is subject to the PRA. An agency may not request nor sponsor, and a person need not answer a request for information that does not contain a valid OMB control no. A response to this request is required to obtain a benefit. The public reporting burden for this form is estimated to average 30 minutes, including the time for reviewing the instructions, gathering and maintaining data, and completing and reviewing the form. Send comments on the burden estimate or any other aspect of this form to Information Collection Clearance Officer–Indian Affairs, 1849 C Street, NW, MS-4141, Washington, DC 20240.