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.