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COLORADO BOARD OF LAND COMMISSIONERS <br />b20 Centennial Building, 1313 Sherman Street <br />Denver, CO 80203, (303) 866-3247 <br />MINERAL ROYALTY REPORT <br />RFCE~V~D <br />APR 1 ~ ?~ <br />Division ~f Minerals and Geology <br />Lease Type LT GM GQGP QR UR CY PL GE GS DW OS OM (CIRCLE ONE) <br />State Lease No. GP 3395 Original X Adjustment <br />County Conejos Production Month & Year December 2002 <br />Lessee Produced and / or Operated By <br />Subsection SEQTR Section(s) 4 Township 36 Range 8 <br />Product Pit Run <br />Urit of Measure YD~ LB OZ BL QT (CIRCLE ONE) <br />3eginning Inventory Units Produced <br />Winding Inventory Units Sold <br />Selling Price per Unit Gross Sales <br />P.cyalty Rate 30 ROYALTY DUE <br />r=or Adjustment Reports. Previous Amount Paid <br />.7dvance Minimum Royalty Credit (if applicable) <br />ROYALTY PAID <br />! this is an adjustment, please explain <br />1975 <br />$592.50 <br />$592.50 <br />Ccntact Name Phil West Telephone No. 719-589.6262 <br />I certify that this is a true and correct statement of production sold, value received, and <br />roe-alty due the State of Colorado for the period indicated. <br />~A thorized Signature & Title <br />Reporting Company Name Alamosa County Road & Bridoe Number 701 <br />Address 8663 South County Road 109 <br />Alamosa, CO 81101-9A23 <br />Subscribed and sworn to before me by <br />On This day of 20_ <br />My Commission Expires 20_ <br />Notary Public <br />Date Stamp Land Board Use Only <br />Verified Receipt No. <br />Notes <br />