Form 101-A NGL Report

Leasing of Osage Reservation Lands for Oil and Gas Mining (25 CFR 226)

Report - NGL Gas

Lessee provides monthly reports

OMB: 1076-0180

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Osage Form 101-A OMB Control No. 1076-XXXX

Revised May 2013 Expires: XX/XX/XXX


Shape1

Meter Station No.

_________________

NGL GAS REPORT

FOR MONTH OF ______________________________________, YEAR:___________


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25CFR 226 – Lessee shall furnish certified monthly reports by the 25th 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:__________

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

Location of meter:_________________________________________________ BTU adjustment:___________________________

PLANT LOCATION DESCRIPTION

Osage Contract Number

¼

SEC

TWP

RGE

Royalty Rate

Type of Gas1

Royalty Amount

(Dollars)

Gallons NOT SOLD

Unit price – price per gallon

Gallon NGL produced

Days Produced

No. of wells produced1

Date last produced MO/DY/YR































































































































1Number of wells actually in operation this month.


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.


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