Michigan Department of Natural Resources Office of Minerals Management – * Mineral Lease Minimum Royalty Remittance *(insert Metallic or Nonmetallic) Required under authority of Part 5, Section 502, Act 451 of 1994, as amended. Check the State of or unpaid balances shall be terms for current rate and due date. At Lessor’s discretion, lease rights shall terminate assessed interest, if payment is not received within timeframe designated in the lease. Contact Office of Minerals Management staff at if you have questions regarding this form. Additional information is available at . Lessee Name Remitter Name Address City State ZIP Contact Person Telephone Email List as many leases as possible, use additional forms as necessary. Minimum Royalty Total State Lease Lease Minimum Royalty Period Pit or Mine Name Rate Per Minimum Number Acres (Mo/Day/Yr) to (Mo/Day/Yr) (if applicable) Royalty to to to to to to to to to to to to to to to to to to to to Signature of Preparer Date TOTAL PAYMENT Make check or money order payable to of and mail “State Michigan” MINIMUM ROYALTY PAYMENT with completed form to: DO NOT WRITE BELOW FOR DNR USE ONLY – CASHIER’S Index PCA AOBJ Production Code Unit of Measure 73590 99059 9167 Minimum Royalty Other CASHIER’S OFFICE MICHIGAN DEPARTMENT OF NATURAL RESOURCES MI 48909-7951 PR4227-4 (Rev. 08/03/2015)
Michigan Department of Natural Resources – Office of Minerals Management * Mineral Lease Minimum Royalty Remittance *(insert Metallic or Nonmetallic) Required under authority of Part 5, Section 502, Act 451 of 1994, as amended. Check the State of terms for current rate and due date. At Lessor’s discretion, lease rights shall terminate or unpaid balances shall be assessed interest, if payment is not received within timeframe designated in the lease. Contact Office of Minerals Management staff at if you have questions regarding this form. Additional information is available at . Lessee Name Remitter Name Address City State ZIP Contact Person Telephone Email List as many leases as possible, use additional forms as necessary. State Lease Number Pit or Mine Name Minimum Royalty Period (Mo/Day/Yr) to (Mo/Day/Yr) Lease Acres Minimum Royalty Rate Per (if applicable) Total Minimum Royalty to to to to to to to to to to to to to to to to to to to to Signature of Preparer Date TOTAL PAYMENT Make check or money order payable to “State of Michigan” and mail with completed form to: CASHIER’S OFFICE MICHIGAN DEPARTMENT OF NATURAL RESOURCES MI 48909-7951 PR4227-4 (Rev. 08/03/2015) MINIMUM ROYALTY PAYMENT DO NOT WRITE BELOW – FOR DNR CASHIER’S USE ONLY Index 73590 PCA 99059 AOBJ 9167 Production Code Minimum Royalty Unit of Measure Other