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~;±' CGI.OKADO DORFC OP LAND COtiM].SSIGNCHS <br />520 Centennial building, 131: ShermZn Strca:t <br />/ 02 Uenuer, CO 80X3, (303) 666-3287 <br />G~l'~ j~L/~l2- taIn'E.;RL ROl'AL7Y REPO P,7 <br />Leas:: Type L7 Gh; ~ GP QR UR C1' PL GE GS Uh' OS OM (CIRCLE OtJc) <br />5'tace Lase No. Ga'z395 Original X Rdjustwent <br />Cour;:y_Coneios _. _ Production :",cnlh & Year tidUeig6~'b1~- ~-Od~. <br />Les:cc .. Producetl ar,dlor OperaCed 0y ~ ~ ~. <br />Sub;e.ction_•SECITR Se.ction(s)_~ ~7ownshi.p fir, ~Ranyc~_~$ <br />Product Pi.t Run <br />Unit of t9 (:a sure )'D 7M LD OT DL OT (CIRCLE OrJE) <br />Deg-nni ng Inventory Units Produced ~~Q ~O _ <br />End:r;y Inventory units So?d ' <br />Sel?ing Price Pur L`.^. ;t Gress Sales <br />Roya"si.y Rate ,?0 ROYALT't DuE <br />For r.oj ustad .P.eport:. Previous Rmount Pais. <br />?dvar.;c Mir:-ir„uut itoya_ty Crepit (if applicable) <br /> RCYAI.TY PR_TC ~..2 / Ic~ <br />IF :;: 'is an are adi~strr,ent, Pl ease explain <br />Contact 'Na;ne_____ p~,; 1,!~.~,_ Telephone No. 719-5,$2-h2h7 ' _ <br />I cert'_Fy that this _. a true and correct statement of production sold, value <br />received, and royalt; cue the State c Cclo.rado For the period indicated. <br />^. <br />~"AUthor:zed Signature G Title <br />, <br />Rcport~ng Comaang Na::.c Alamosa County Road & Bridge 'Number ~n,~ , <br />Rddress 8663 S. County Road 109 _ <br />' Alamosa. CO 81101-9423 <br />SUuSC!'_G2d anc s'a.~orn o before me by <br />OG ihis day cr <br />I1y 'Conmission Expires <br />' Nc:ary Public <br />Cate Jtamp Land Guard Use Only <br />:9 <br />19__ -- <br />Verified Receipt No <br />Posted <br />Notes_ <br />Dat <br />