Michigan Department of Natural Resources Office of Minerals Management Remitter Name – Uniform Production and Royalty Remittance Page of Address Required under authority of Part 5, Section 502, Act 451 of 1994, as amended. City State ZIP Contact Person Telephone Number NOTE: Submission of this information is required pursuant to lease terms and conditions. Noncompliance with lease requirements may result in ( ) placement on the Hold Action List and/or other legal remedies as determined necessary. Column Key: Provided on the reverse side. (A) (B) (C) (D) (E) (F) (G) (H) (J) (L) (M) (N) (O) (P) (Q) (S) (I) (K) (R) Property Well 100% Mmbtu % of Vol Payment / Permit Prod Prod Prod Gross PSI Conv $ - Gross $ - Gross Decimal $ - State Gross Cost $ - Gross $ - Net Cash Basis Paying For $ - Net Costs Well ID # Producing Unit Name Number Type Month Year Volume Basis Factor Price Revenue Interest Royalty Code Costs Royalty Signature of Remitter: Date: $ SUMMARY OF NET CASH ROYALTY: ** Do Not Write Below For ** – DNR Cashier’s Use Only Make check or money order payable to of (do not send cash) and mail with completed form. “State Michigan” MAIL: OVERNIGHT EXPRESS: CASHIER’S OFFICE CASHIER’S OFFICE MICHIGAN DEPARTMENT OF NATURAL RESOURCES MICHIGAN DEPARTMENT OF TRANSPORTATION PO BOX 30451 VAN WAGONER BUILIDING, FIRST FLOOR LANSING MI 48909-7951 425 WEST OTTAWA STREET LANSING MI 48933 LANSING MI 48909-7951 PR4227-7 (Rev. 08/06/2015)
Remitter Name Michigan Department of Natural Resources – Office of Minerals Management Uniform Production and Royalty Remittance Required under authority of Part 5, Section 502, Act 451 of 1994, as amended. Page of Address City State ZIP Contact Person Telephone Number ( ) NOTE: Submission of this information is required pursuant to lease terms and conditions. Noncompliance with lease requirements may result in placement on the Hold Action List and/or other legal remedies as determined necessary. Column Key: Provided on the reverse side. (A) Property Payment / Well ID # (B) Producing Unit Name (C) Well Permit Number (D) Prod Type (E) Prod Month (F) Prod Year (G) 100% Gross Volume (H) PSI Basis (I) Basis (J) Mmbtu Conv Factor (K) % of Vol Paying For (L) $ - Gross Price (M) $ - Gross Revenue (N) Decimal Interest (O) $ - State Gross Royalty (P) Cost Code (Q) $ - Gross Costs (R) $ - Net Costs (S) $ - Net Cash Royalty Signature of Remitter: Date: SUMMARY OF NET CASH ROYALTY: $ Make check or money order payable to “State of Michigan” (do not send cash) and mail with completed form. ** Do Not Write Below – For DNR Cashier’s Use Only ** MAIL: CASHIER’S OFFICE MICHIGAN DEPARTMENT OF NATURAL RESOURCES PO BOX 30451 LANSING MI 48909-7951 LANSING MI 48909-7951 OVERNIGHT EXPRESS: CASHIER’S OFFICE MICHIGAN DEPARTMENT OF TRANSPORTATION VAN WAGONER BUILIDING, FIRST FLOOR 425 WEST OTTAWA STREET LANSING MI 48933 PR4227-7 (Rev. 08/06/2015)
PR4227-7_489547_7.docx