Tank Bottom Oil Report Form

Bureau of Indian Affairs/Osage Agency

P.0. Box 1539 Pawhuska, OK 74056-1539

918-287-5740

TANK BOTTOM OIL REPORT FOR THE MONTH OF: YEAR:

REPORTING COMPANY TANK BOTTOM PURCHASER

	Contact Person
	Reporting Company ( ) -
		NAME & ADDRESS

Phone Number

**

^GROSS NET ROYALTY $

DATE TICKET LEGAL OPERATOR BARRELS BS&W BARRELS BARRELS ROYALTY

				GRAND TOTALS: I		I		I	II I

TOTAL NET BARRELS:

TOTAL ROYALTY BARRELS:

(1/6 of net barrels or as negotiated)

TOTAL ROYALTY:

( ** Royalty barrels x purchaser's price)

I certify that the foregoing report is true and correct:

SIGNATURE REQUIRED

A REPORT MUST BE SUBMITTED TO THIS OFFICE ON OR BEFORE THE 25TH OF EACH'MONTH FOLLOWING SALES. REPORTS ARE REQUIRED EVEN THOUGH NO SALES OCCUR.