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CGLOkADO 80ARD Of LAND C014MlSSIGNCkS <br />520 Centennial Building, 113 Sherm;rn Strcc•.t <br />~Uonver, CO 602C3, (303) 666-32A7 <br />i4INERAL ROYALTY REPORT <br />Lease. Type LT GM GL . GP Q3 L'R C1' PL GE GS Dt1~ OS OM (CIRCLE ONE) <br />State Lease n'o. OP3395 Original % Adjustment <br />County- Conei~s Production v~cnlh u Ygar [~'~ /1"~,(3a2.. <br />lessee ~ Produced andlor Operated 6y ~ . <br />SuSsectAon_"SEOTR Sectian(s)_~4 'Iownshi.p ~6,. ^Ranyo R <br />Product Pit Run <br />Unit of t4Gdsurt'. YD •fPl LB OT D~ OT (CIRCLE ONE) <br />Beginning Inventory Units Produced <br />Ending Inventory Units Sold <br />Selling Price Per Unit Gress Sales <br />Royalty Rate .30 ROYALTY OUE <br />For adjusted .Reports, Previous Rmount Paid. <br />Rdvance.Minimum Roya_ty CrecJit (if applicable) <br />KOYAI,TY PaIO <br />If t;tis 'is an an adj~stn~ent, please explain <br />Contact'Narne pr,;; Glac'r Telephone rlo. 71~_5,~j,g-{~,~~ _ <br />I certify .that this is a°true and correct statement of production sold, value <br />received, and royalty cue tha State o` Celo,rado for tlic period indicated. <br />~~i~-- <br />AUthOrized Signature G Title <br />Reporting Company Narnu Alamosa County Road & Bridge 'Number ~~ , <br />address 8663 S. County Road 109. _ <br />Alamosa CO 81101-4423 <br />Subscribed and s'~orn to before the by <br />Or. This day or" _:9 • <br />I'iy 'COnmission Expires 19, <br />' Nctary. Public <br />Oate' Stamp land Board Use Only <br />Verified ____-Receipt No. <br />~l-3" _ <br />~99~- a <br /> <br />Posted Date <br />.Notes ~ _ _- .~._. <br />