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CGLOKADO EiOARD OF LAraD COr4M7.5SI'ONCN,S <br />520 Centennial Building, 1~1? Sherman Strr,-gt <br />Oenucr, CO 80203, (303) &6G-32A7 <br />raIn'ERaI RO1'aLTY REPORT <br />Loaso Type. LT Grt .,L GP q? UR CT PL GE CS Dw' OS CM (CIRCLE ON=) <br />S'catc L;edsc NU. GP3395 Original X ;,djustment <br />Co;:nt.yiC~n;jos _ _ Production v~enlh & Year~,(~~J ~00`~- <br />l.essee ~ Produc Cd andlor Ope ra ced Ely , <br />Subscc'caon_'SEQTR 5ection(s)~4 7ownshi.p ~ ~rtangc: 8 <br />Pr'uduci Pit Run <br />Unit cf measure YD 'frr l.9 OZ ©: OT (CIRCLE OWE) <br />ReginnLL.~g Inventory Units Produced <br />Endinu Inventory Units Sold <br />Sellsr!~: Price Per Unit ~ Cress Sales <br />Royal t Ratc .30 ROYALTY CUE <br />For },dj.:;Led .P.ePorts: Previous Amount Paid. <br />Advance,i':iniraual Roya_ty Credit {if applicable) <br />RCYALTY PAID <br />If t~iis'is an an adj~stmcnt, please explain <br />_~~G,~G . o b _ <br />`3 g/s" ~ <br />_~ l5-'~ Db <br />Contact't•.~::rne Ph;i ja~~_ 7e2ephone nro. 719-589-fi2h7 _ <br />S certify that this _, a true and correct statement or" production sold, value <br />received, and royalty cue the State of Cclo.rado f~o~^ the per~oci indicated. <br /> <br />authorized Signature G Title <br />Reporting Compang PJamc AlamosaCounty Road & Bridge 'NUmb•ar ~ t <br />Address R6b 3 S. Coun v Read 109 ._ <br />Alamosa. CO 81101-9423 <br />5Ub5cribed :nc ;worn ':v before1 me by -{-~~1f ~ ~IS>-~1 1l <br />O n This l ~ day o r" ~-'•-~-~-~` _~ ~dU~'- <br />1'~, 'Conrnission Expirr.s~0."ti ~- _~.~~~ <br />N c_ a r y. P u o l i c~.G~lrrn v,---~c~~- ~.^--_ <br />Cate' StamF <br />Land Coard Use Only <br />verified <br />Receipt No <br />Posted oat <br />Notes <br />