Form 3195-1 Calculatoin of Excess Refining Capacity

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Form 3195-1
(April 2016)

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BUREAU OF LAND MANAGEMENT
AMARILLO FIELD OFFICE
ATTN: Assistant Field Manager for Operations
801 S. Fillmore, Suite 500
Amarillo, Texas 79101

Submit Form To:

OMB Control No.: 1004-0179
Expires: 11/30/2018

CALCULATION OF EXCESS REFINING CAPACITY
FISCAL YEAR:

DESCRIPTION

Volumes in million scf/yr
YEAR END ACTUALS
(BLM Use Only)

REFINER’S FORECAST

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:
Telephone:
Email:

Title:
Printed Name of Authorized Agent:
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.
Form 3195-1