Form 3195-2 Refiners' Annual Tolling Report

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Form 3195-2
(April 2016)

Submit Form To:

FISCAL YEAR:

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

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

: Submit annually by October 15 of each year

Volumes in million scf/yr
Company

Date Tolling
Agreement
Signed

Volume

Price
(Per MCF)

Delivery Period

Voluntary Disclosure: (1) Tolling agreements for less than 15 million standard cubic feet of helium; and (2) Efforts to reach tolling agreements
that did not result in an agreement (please discuss any offers or efforts through the reporting year to enter tolling agreements, include attachments
as needed):

I certify that the information provided above accurately describes the tolling agreements with non-refiner storage contract holders in the
Federal Helium Program required by law to be disclosed and agreements voluntarily disclosed. 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 purposes.
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 3195-2