Form 3195-4 refined Helium Deliveries Detail

Form 3195-4 OMB Control No. 1004-0179

(April 2016) Expires: 10/31/2021

Refined Helium Deliveries Detail

U.S. Department of the Interior Bureau of Land Management Amarillo Field Office, Amarillo, Texas

Reporting Date (from/to):

The information in this report is required by contract. The Bureau of Land Management may levy fines or terminate a contract with a Federal Helium Supplier for failure to comply with the reporting provisions specified by contract.

The information in this report is required by 43 CFR Part 3195 regulations.

Each Federal Helium Supplier should prepare this report for each quarter it has made refined helium deliveries to a Federal Agency or Federal Agency Contractor. Each Federal Agency should prepare this report for each quarter it or one of its contractors has received refined helium deliveries from a Federal Helium Supplier.

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 8 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.

Section 1. Agency Identification:

Agency Name / POC & Phone Helium Supplier / Contract # Billing Address

Section 2. Refined Sales Detail

* Enter pressure and temperature conditions if volume is reported in cubic feet.

Federal Agency (Federal End User)	Location or Delivery Point (City, ST)	Delivery Date (formatted as date)	Volume (a number)	Units* (cubic feet @ P&T, liters, or gallons)	Reference or Invoice Number (for audit purposes)

* Enter pressure and temperature conditions if volume is reported in cubic feet.