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.