Form 301 Tank Bottom Oil Report

Osage Form 301 OMB Control No. 1076-XXXX

Revised May 2013 Expires: XX/XX/XXX

TANK BOTTOM OIL REPORT

FOR MONTH OF ______________________________________, YEAR:___________

25 CFR 226 –reports must be submitted by the 25^th of each month FOLLOWING SALES. REPORTS ARE REQUIRED EVEN THOUGH NO SALES OCCUR.

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

REPORTING COMPANY		TANK BOTTOM PURCHASER
	Contact Person
	Reporting Company
	( ) -

Phone Number Name & Address

Date	Ticket	Legal	Operator	Gross Barrels	BS&W	Net Barrels	Royalty Barrels	Royalty** ($)
			GRAND TOTALS:

TOTAL NET BARRELS: _________________________________

TOTAL ROYALTY BARRELS: _____________________________

(1/6 of net barrels or as negotiated)

TOTAL ROYALTY: _____________________________________

(**Royalty barrels x purchaser’s price)

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.