Form 101, Form 101 Form 101, Form 101 Monthly Accounting Forms

Leasing of Osage Reservation Lands for Oil and Gas Mining (25 CFR 226)

Osage Monthly Accounting Forms - 133 157 300 101 101A

Lessee submits monthly royalty report

OMB: 1076-0180

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OSAGE FORM NO. 133

ast(white)


OIL LESSEE’S REPORT FOR MONTH OF _______________________________________ YEAR______________________________


UNITED STATES

DEPARTMENT OF THE INTERIOR

BUREAU OF INDIAN AFFAIRS

CFR 226.26 – LESSEE SHALL FURNISH CERTIFIED MONTHLY REPORTS BY THE END OF EACH MONTH COVERING ALL OPERATIONS, WHETHER THERE HAS BEEN PRODUCTION OR NOT.

SUPERINTENDENT, OSAGE AGENCY

BRANCH OF MINERALS

813 GRANDVIEW/POB 1539

PAWHUSKA, OK 74056

(918) 287-5740 FAX(918) 287-5784


LESSEE ID#__________


LESSEE NAME______________________________________________________ CURRENT PHONE#__________________________

ADDRESS______________________________________________________________________________________________________


CITY_________________________________________________ STATE_____________________________ ZIP__________________

LEGAL DESCRIPTION

OSAGE

CONTRACT #


DIVISION ORDER #(2)



1/4



SEC.



TWP



RGE


PURCHASER


(ROYALTY PAID BY)


BBLS. OIL

SOLD


ROYALTY

RATE


ROYALTY

AMOUNT

(dollars)


BBLS OIL

PRODUCED

# WELLS

PRO-

DUCED

(1)


DAYS

PRO-

DUCED


DATE

LAST

PRODUCED

MO/DY/YR


__________















__________















__________















__________















__________















__________















__________















__________















__________















__________














(1) NUMBER OF OIL WELLS ACTUALLY IN OPERATION THIS MONTH.

(2) OIL PURCHASER DIVISION ORDER NUMBER


I CERTIFY THE FOREGOING REPORT IS TRUE AND CORRECT.




__________________________________________________________________________ ______________________________________________________________

SIGNATURE AND TITLE TELEPHONE NUMBER


OSAGE FORM NO. 157

ast(blue)

FOR CONSOLIDATED LEASES ONLY


OIL LESSEE’S REPORT FOR MONTH OF _______________________________________ YEAR______________________________


UNITED STATES

DEPARTMENT OF THE INTERIOR

BUREAU OF INDIAN AFFAIRS

S

CFR 226.26 – LESSEE SHALL FURNISH CERTIFIED MONTHLY REPORTS BY THE END OF EACH MONTH COVERING ALL OPERATIONS, WHETHER THERE HAS BEEN PRODUCTION OR NOT.


UPERINTENDENT, OSAGE AGENCY

BRANCH OF MINERALS

813 GRANDVIEW/POB 1539

PAWHUSKA, OK 74056

(918) 287-5740 FAX(918) 287-5784


LESSEE ID#_____________


LESSEE NAME_________________________________________________ CURRENT PHONE#_______________________________


ADDRESS______________________________________________________________________________________________________


CITY __________________________________________________ STATE_____________________________ ZIP_________________

LEGAL DESCRIPTION

OSAGE

CONTRACT #


DIVISION ORDER #(4)



1/4



SEC



TWP



RGE


PURCHASER


(ROYALTY

PAID BY)


BBLS. OIL

SOLD

(1) (3)


ROYALTY

RATE


ROYALTY

AMOUNT

(dollars)

(1) (3)


BBLS OIL

PRODUCED

(1) (3)


#

WELLS

PRO-DUCED

(2)


DAYS

PRO-

DUCED



DATE

LAST

PRODUCED

MO/DY/YR


__________



















__________





















__________























__________















__________














__________













_________















__________















__________















(1) OIL AND ROYALTY FROM EACH QUARTER SECTION OF CONSOLIDATION MUST BE ACCOUNTED FOR SEPARATELY

(2) NUMBER OF OIL WELLS ACTUALLY IN OPERATION THIS MONTH.

(3) COLUMN IS TO BE TOTALED FOR EACH CONSOLIDATION

(4) OIL PURCHASER DIVISION ORDER NUMBER


I CERTIFY THE FOREGOING REPORT IS TRUE AND CORRECT.




___________________________________________________________________________ ____________________________________________________________ SIGNATURE AND TITLE TELEPHONE NUMBER



OSAGE FORM NO. 300

ast(pink)

FOR WATERFLOOD LEASES ONLY (1)


OIL LESSEE’S REPORT FOR MONTH OF _____________________________________________ YEAR________________________


UNITED STATES

DEPARTMENT OF THE INTERIOR

BUREAU OF INDIAN AFFAIRS

S

CFR 226.26 – LESSEE SHALL FURNISH CERTIFIED MONTHLY REPORTS BY THE END OF EACH MONTH COVERING ALL OPERATIONS, WHETHER THERE HAS BEEN PRODUCTION OR NOT

UPERINTENDENT, OSAGE AGENCY

BRANCH OF MINERALS

813 GRANDVIEW/POB 1539

PAWHUSKA, OK 74056

(918) 287-5740 FAX(918) 287-5784


LESSEE ID#_____________


LESSEE NAME_________________________________________________ CURRENT PHONE#_______________________________


ADDRESS______________________________________________________________________________________________________


CITY____________________________________________ STATE___________________________ ZIP_________________________

LEGAL DESCRIPTION

OSAGE

CONTRACT #


DIVISION

ORDER #(5)


(2)


¼



UNIT


SEC.


NAME


TWP




RGE



PURCHASER

(ROYALTY PAID BY)


BBLS. OIL

SOLD


ROYALTY

RATE

(3)


ROYALTY

AMOUNT

(dollars)


BBLS OIL

PRODUCED

# WELLS

PRO-

DUCED

(4­)


DAYS

PRO-

DUCED


DATE

LAST

PRODUCED

MO/DY/YR


__________














__________











__________















__________















__________















__________















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__________















__________














  1. This form is completed on leases approved for waterflood units by The Osage Minerals Council.

  2. Information must include name of waterflood unit and indicate the specific quarter section oil is posted to on Agency computer

(Legal description can be obtained from Branch of Minerals, 918-287-5740).

  1. If different royalty rates apply – specify rate and amount at each rate.

  2. Number of oil wells actually in operation this month.

  3. Oil Purchaser Division Order Number.

I CERTIFY THE FOREGOING REPORT IS TRUE AND CORRECT.



________________________________________________________ _________________________________

SIGNATURE AND TITLE TELEPHONE NUMBER

OSAGE FORM NO. 101

(green)

METER STATION NO: _______________________________


DRY GAS REPORT FOR MONTH OF __________________________________, YEAR: ______________________


UNITED STATES

DEPARTMENT OF THE INTERIOR

BUREAU OF INDIAN AFFAIRS

T

CFR 226.26 – LESSEE SHALL FURNISH CERTIFIED MONTHLY REPORTS BY THE END OF EACH MONTH COVERING ALL OPERATIONS, WHETHER THERE HAS BEEN PRODUCTION OR NOT

O SUPERINTENDENT, OSAGE AGENCY

BRANCH OF MINERALS

813 GRANDVIEW

P. O. BOX 1539

PAWHUSKA, OK 74056

(918) 287-5740 FAX(918) 287-5784

LESSEE ID NO: _____________


LESSEE NAME:_______________________________________________ CURRENT PHONE NO: _____________________________


ADDRESS: ________________________________CITY: ___________________ STATE: _____________ ZIP: _________________


GAS PURCHASER:_______________________________________________PURPOSE: DOMESTIC/SALES/OTHER (CIRCLE ONE)


LOCATION OF METER: __________________________________________ BTU ADJUSTMENT: ___________________________

LEASE DESCRIPTION


OSAGE

CONTRACT

NUMBER




¼



SEC



TWP



RGE


ROYALTY

RATE


TYPE

OF

GAS

(1)


ROYALTY

AMOUNT




MCF


UNIT PRICE

PAID

PER/MCF


PRICE

PAID

PER

MMBTU


NO. OF

WELLS

PRO-

DUCED


DATE

LAST

PRODUCED

MO/DY/YR








































































































































(1) USE: CHG (CASINGHEAD); NG – NATURAL GAS (GAS WELL GAS); CBM – COAL BED METHANE

2. CONSOLIDATED GAS LEASES - PRODUCTION FROM EACH QUARTER SECTION OF CONSOLIDATION MUST BE ACCOUNTED FOR SEPARATELY AND COLUMN IS TO BE TOTALED FOR EACH CONSOLIDATION.


I CERTIFY THAT THE FOREGOING REPORT IS TRUE AND CORRECT.




_____________________________________________________________________________________ ____________________________________________

SIGNATURE AND TITLE TELEPHONE NUMBE


OSAGE FORM NO. 101-A

(yellow)

METER STATION NO: _______________________________


NGL GAS REPORT FOR MONTH OF __________________________________, YEAR: _____________________


UNITED STATES

DEPARTMENT OF THE INTERIOR

BUREAU OF INDIAN AFFAIRS

T

CFR 226.26 – LESSEE SHALL FURNISH CERTIFIED MONTHLY REPORTS BY THE END OF EACH MONTH COVERING ALL OPERATIONS, WHETHER THERE HAS BEEN PRODUCTION OR NOT

O SUPERINTENDENT, OSAGE AGENCY

BRANCH OF MINERALS

813 GRANDVIEW

P. O. BOX 1539

PAWHUSKA, OK 74056

(918) 287-5740 FAX(918) 287-5784

LESSEE ID NO: _____________


LESSEE NAME:_______________________________________________ CURRENT PHONE NO: _____________________________


ADDRESS: ________________________________CITY: ___________________ STATE: _____________ ZIP: _________________


NGL PURCHASER:_______________________________________________PURPOSE: DOMESTIC/SALES/OTHER (CIRCLE ONE)


LOCATION OF METER: __________________________________________ BTU ADJUSTMENT: ___________________________

PLANT LOCATION DESCRIPTION


OSAGE

CONTRACT

NUMBER




¼



SEC



TWP



RGE


ROYALTY

RATE


TYPE

OF

GAS

(1)


ROYALTY

AMOUNT

(Dollars)


Gallons

NGL

SOLD




UNIT PRICE


Price per

Gallon



GALLON

NGL

PRO-

DUCED



DAYS

PRO-

DUCED


NO. OF

WELLS

PRO-

DUCED

(1)


DATE

LAST

PRODUCED

MO/DY/YR

















































































































































1. NUMBER OF WELLS ACTUALLY IN OPERATION THIS MONTH.


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 display 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 and maintaining data, and completing and 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-3642, Washington, DC 20240.


File Typeapplication/msword
File TitleOSAGE FORM NO
AuthorOsage Agency
Last Modified ByAmanda
File Modified2015-03-11
File Created2015-03-05

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