Lease Status 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

I II

OMB Control No. 1076-0180
Expiration Date xx/xx/xxxx

DISPOSAL OR INJECTION WELL INFORMATION

Paperwork Reduction Act Statement: We are collecting this information subject to the Paperwork Reduction Act (44 U.S.C. 3501) to identify and
monitor lease operations and protection of trust asset. 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.

OMB Control No. 1076-0180
Expiration Date xx/xx/xxxx