Form 300 Oil Lessee Waterflood Report

Osage Form 300 OMB Control No. 1076-XXXX

Revised May 2013 Expires: XX/XX/XXX

FOR WATERFLOOD LEASES ONLY¹

OIL LESSEE’S REPORT

FOR MONTH OF ______________________________________, YEAR:___________

25 CFR 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.5

¼2

SEC

TWP

RGE

Purchaser (Royalty paid by)

BBLS oil sold

Royalty Rate3

Royalty Amount1,3

BBLS oil produced1,3

No. of wells produced4

Days Produced

Date last produced MO/DY/YR

¹ This form is to be completed on all leases approved for waterflood units by the Osage Minerals Council.

² Information must include name of waterflood unit and indicate the specific quarter section that oil is posted to on Agency computer (Legal description can be obtained from BIA)

³ If different royalty rates apply – specify rate and amount at each rate.

⁴ Number of oil wells actually in operation this month.

⁵ Oil 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 & maintaining data, and completing & 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.