Form 2014 Report of Sales and Royalty Remittance

REPORT OF SALES AND ROYALTY REMITTANCE
FORM 2155-2014

PAYOR NAME: _____________________________________

2

PAYOR CODE: __ __ __ __ __

5

6

13

14

15

ADJUSTMENT
REASON CODE

12

TRANSACTION
CODE

API WELL NUMBER

MMS
AGREEMENT NUMBER

11

SALES
MO/YR
(MMCCYY)

9

8

10
ONRR
LEASE NUMBER

SALES
TYPE CODE

7
RESERVED FOR
PREPARER’S USE

3 FEDERAL/INDIAN REPORT INDICATOR

(F or I)

4 PAYOR-ASSIGNED
DOCUMENT NUMBER __ __ __ __ __ __ __ __

PRODUCT
CODE

LINE NUMBER

1

OMB Control Number 1012-0004
OMB Approval Expires 12/31/2015

16
SALES VOLUME
(Mcf/bbl/gal/long ton)

19

For ONRR Use Only

ROYALTY VALUE
PRIOR TO ALLOWANCES
$

17
GAS MMBtu

20

TRANSPORTATION
ALLOWANCE
DEDUCTION $

18
SALES VALUE
$

21

22

PROCESSING
ALLOWANCE
DEDUCTION $

INTENTIONALLY
LEFT
BLANK
ROYALTY VALUE
LESS ALLOWANCES
$

23

PAYMENT
METHOD CODE

U.S. DEPARTMENT OF THE INTERIOR
Office of Natural Resources Revenue

1

2

3

4

Authorized Name (print) and Signature

Date

If company contact information has changed, please indicate below: (Please print)
Contact Name
Street
City
Fax Number
Form ONRR-2014 (revised 12/2009)

Phone Number
P.O. Box

Suite or Other Identifier

State

Zip Code
Email Address

PAYMENT INFORMATION

I have read and examined the statements in this report and agree they are accurate and complete.

PAGE
TOTAL

Checks To ONRR (PM1)
________________
REPORT
*Indian Direct Pay (PM2)
________________
TOTAL
EFT Payments (PM3)
________________
*Royalty-In-Kind (PM4)
________________
Checks To ONRR For BIA (PM5)
________________
________________
Other (For Future Use) (PM6)
*Indian Lockbox (PM7)
________________
Total All Payments:
________________
=
Less Available Credits: (*Credits may not be applied to PM2, PM4, PM7)
Doc. ID: _________________
_______________
Doc. ID: _________________
________________
Doc. ID: _________________
________________
Net Payment for this Report:
= ________________
$

PAGE ____ OF _____

REPORT OF SALES AND ROYALTY REMITTANCE
FORM ONRR-2014

INSTRUCTIONS
This form is used to report royalties and other obligations due on Federal and Indian oil
and gas, and geothermal leases. For detailed instructions and examples on how to
complete and submit this form, please refer to the Minerals Revenue Reporter Handbook.
If you need to speak with someone about your reporting, call 1 (800) 525-0309 or
1 (800) 525-7922.
Send completed Form ONRR-2014 to:
Office of Natural Resources Revenue
P.O. Box 25627
Denver, Colorado 80225-0627
Paperwork Reduction Act of 1995 (PRA) Statement: The PRA (44 U.S.C. 3501 et seq.) requires us to
inform you that we collect this information to document details of royalty payments and sales of minerals
from leases on Federal and Indian lands. The ONRR uses the information to maintain and audit lease
accounts. Responses are mandatory (43 U.S.C. 1334) and submitted monthly to report royalties on oil,
gas, and geothermal leases, certain rents, and other lease-related transactions (e.g., transportation and
processing allowances, lease adjustments, and quality and location differentials). Proprietary information
is protected in accordance with standards established by the Federal Oil and Gas Royalty Management
Act of 1982 (30 U.S.C. 1733), the Freedom of Information Act [5 U.S.C. 552(1), (4)], and Department
regulations (43 CFR 2). An agency may not conduct or sponsor, and a person is not required to respond
to, a collection of information unless it displays a currently valid OMB Control Number. The public
reporting burden for this form is estimated to average 3 minutes per line for electronic reporting and 7
minutes per line for manual reporting. These estimates include the time for reviewing instructions,
gathering and maintaining data, and completing and reviewing the form. Direct any comments regarding
the burden estimate or any other aspect of this form to the Office of Natural Resources Revenue,
Attention: Rules & Regs Team, P.O. Box 25165, Denver, CO 80225-0165.