Tank Bottom Oil Report Form

OMB Control No. 1076-0180

Expiration Date xx/xx/xxxx

OMB Control No. 1076-0180

Expiration Date xx/xx/xxxx

OMB Control No. 1076-0180

Expiration Date xx/xx/xxxx

OMB Control No. 1076-0180

Expiration Date xx/xx/xxxx

OMB Control No. 1076-0180

Expiration Date xx/xx/xxxx

OMB Control No. 1076-0180

Expiration Date xx/xx/xxxx

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.

Paperwork Reduction Act Statement: We are collecting this information subject to the Paperwork Reduction Act (44 U.S.C. 3501) to ensure appropriate royalties to owners are paid. Your response is voluntary and we will not share the results publicly. We may not conduct or sponsor and you are not required to respond to a collection of information unless it displays a currently valid OMB Control Number. OMB has reviewed and approved this survey and assigned OMB Control Number 1076-0180, which expires ##/##/####.

Estimated Burden Statement: We estimate the form will take you 3 hours to complete, including time to read instructions, gather information, and complete and submit the form. You may submit comments on any aspect of this information collection to the Information Collection Clearance Officer, Office of Regulatory Affairs & Collaborative Action—Indian Affairs (RACA), U.S. Department of the Interior, 1001 Indian School Road NW, Suite 229, Albuquerque, NM 87104.