Form 101, Form 101 Monthly Accounting Forms

OMB Control No. 1076-0180

Expiration Date xx/xx/xxxx

OSAGE FORM NO. 133

ast(white)

OIL LESSEE’S REPORT FOR MONTH OF _______________________________________ YEAR______________________________

UNITED STATES

DEPARTMENT OF THE INTERIOR

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.

BUREAU OF INDIAN AFFAIRS

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

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FOR CONSOLIDATED LEASES ONLY

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 #(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

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 #(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

__________

__________

__________

__________

__________

__________

__________

__________

__________

__________

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).

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

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

5. 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

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

TO 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

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

TO 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 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 30 minutes 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.