Form 133 Oil Lessee Report

Osage Form 133 OMB Control No. 1076-XXXX

Revised May 2013 Expires: XX/XX/XXX

OIL LESSEE’S 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:___________________

LEGAL DESCRIPTION

Osage Contract No. Division Order No.2

¼

SEC

TWP

RGE

Purchaser (Royalty paid by)

BBLS oil sold

Royalty Rate

Royalty Amount

BBLS oil produced

No. of wells produced1

Days Produced

Date last produced MO/DY/YR

¹Number of oil wells actually in operation this month.

²Oil purchaser division order number.

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.