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COLOkADO FiUARD Of LAND COt4MJ.5SIGNCHS <br />52G Centennial Building, 1~1? Sherman Strreet <br />Uenurr, CG B02C3, (303) 666-3<<^A7 <br />"INERaL R01'AL7Y REPORT <br />Lease Type LT GN, G GP QR UR G1' PL GE GS C'ti 05 OM (CIRCL% ON:) <br />State Lease No. GP3395 Original Adjusttnent~_ <br />County Conejos _ Pr oduction i"~onlh ~: Year ~ ! ~IO~_ <br />lessee _ Produced and/or Operated Jy <br />iubsect[:on_~SEOTP. Section!s),4 Townshi.p_i~~ ____Ran9o__„~~~, <br />Pr'oduc,t_ Pit Run <br />Unit or tacasurc>. YO Pl l.8 OZ 4:. OT (CIRCLE OrJE) <br />~e9inning T_nventory Units Producec <br />Ending Inventory Units Sold <br />Selling Price Per Unit Cress Sales <br />Royally Rate .30 ROYALT't CUE <br />For r',c.~usted .Reports, Previous Amount Paid. <br />Advanc::>"ini;rum ftoya'_ty CrP.dit (if app]icab]c) <br />ftCYAI,TY PAID <br />If this 'is an an adj~strr;ent, please explain <br />u~lao _ <br />/0~,~ ~6 <br />Contact 'Name ph; 1 ~.cr Telephone n1o. 719-SA.Q~Fj2(t7 _ <br />I certi.'y that this is a'true and correct statement of production sold, value <br />received, and rolalty dui the State. of Cclo.rado for the period indicated. <br />thorized Signature Z Title <br />Rr,portir.9 Company Narnv Alamosa County Road & Bridge Number X03 . <br />Address 8663 S. County Road 109 <br />Alamosa, CO 81101-9423 <br />Subscribed and sworn to before me by <br />Or. This day or` _:9 <br />hiy 'COmrnission Expires_-____ ?9, <br />Nc:ary Public <br />Oate'Stamp land Loard Use Only <br />Verified <br />Poste' <br />Notes <br />eceipt No. <br />ate <br />