Osage Form 101-A OMB Control No. 1076-XXXX
Revised May 2013 Expires: XX/XX/XXX
Meter Station No.
_________________
FOR MONTH OF ______________________________________, YEAR:___________
25CFR 226 – Lessee
shall furnish certified monthly reports by the 25th
of each month covering all operations, whether there has been
production or not.
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 |
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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.
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | elizabeth.appel |
File Modified | 0000-00-00 |
File Created | 2021-01-29 |