Form 3195-1 Calculation of excess refining capacity

Form 3195-1	OMB Control No. 1004-0179
(June 2015)	Expires:

Submit Form To:

BUREAU OF LAND MANAGEMENT

AMARILLO FIELD OFFICE

ATTN: Assistant Field Manager for Operations

801 S. Fillmore, Suite 500

Amarillo, Texas 79101

CALCULATION OF EXCESS REFINING CAPACITY

FISCAL YEAR: __________

Volumes in million scf/yr

DESCRIPTION	REFINER’S FORECAST	YEAR END ACTUALS (BLM Use Only)	FORECAST VS. ACTUAL (BLM Use Only)
Operational Refining Capacity (The total capacity available to refine crude helium, including capacity that could reasonably be put into operation for the forecasted fiscal year.)
Planned Demand (The planned demand for all crude helium to be processed by the helium refiner. This includes crude helium from the Federal Helium system, as well as from all other sources.)
Equals: Excess Refining Capacity (The reported total refining capacity of the refiner, minus the volume of forecasted demand for a particular fiscal year.)

I certify that the information provided above accurately describes the excess refining capacity, required by the Helium Stewardship Act of 2013. I understand that this information will be treated as business sensitive by the BLM, but will be aggregated with other refiners’ data for the BLM’s public reporting purposes.

Additionally, I understand that variations of this data (+/- 10%) must be reported to the BLM within 14 days of knowledge of the change. Pursuant to terms and conditions of sale, as specified in the Helium Stewardship Act of 2013, I understand that failure to provide this information or subsequent changes to this information, may bar the company from participation in helium auctions and/or sales.

Company Name:__________________________________ Title:_________________________________________

Telephone:________________________ Printed Name of Authorized Agent:_______________________________

Email:____________________ Signature:__________________________________ Date:____________________

PAPERWORK REDUCTION ACT (PRA) STATEMENT: The PRA (44 U.S.C. 3501-3521) requires us to inform you that we collect this information to obtain documentation of refined helium deliveries. The BLM uses this information to monitor compliance with a statutory requirement that sellers of refined helium to federal agencies buy an equivalent amount of crude federal helium. Responses are required to obtain or retain a benefit (43 CFR 3195 and 50 U.S.C. 167d(b)(8)). In order to ensure the confidentiality of information submitted on this form, the BLM will aggregate the information obtained and disclose it publicly only in the aggregate. You do not have to respond to this or any other Federal agency-sponsored information collection unless it displays a currently valid OMB control number. The public reporting burden for this form is estimated to be 4 hours per response, including the time for reviewing instructions, gathering and maintaining data, and completing and reviewing the form. You may send direct comments regarding the burden estimate or any other aspect of this form to the U.S. Department of the Interior, Bureau of Land Management (1004-0179), 1849 C Street, NW, Room 2134LM, Attention: Bureau Information Collection Clearance Officer (WO-630), Washington, DC 20240.