Addition To Exemption Application
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1Addition to Exemption
KSA 79-201t
Page 1 of 1
Applicant Name: ________________________
Docket No.:_____________________________
Addition to Exemption Application
Low Producing Oil Lease
K.S.A. 79-201t
1.
Enclose a copy of the oil assessment rendition(s) showing monthly production for the year(s) that
you are requesting exemption.
2.
Does the rendition report any month(s) with zero production? _____ No _____Yes
3.
If “yes”, for the months with zero production reported, explain the lack of production, i.e. the
well(s) was/were shut-in, down for maintenance or simply not producing.
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
4.
If the well(s) was/were producing for the month(s) with a zero production reported, how many days
of the month(s) was/were the well(s) producing?
___________________________________________________________________________
VERIFICATION
I, ________________________________, do solemnly swear or affirm that the information set forth herein
is true and correct, to the best of my knowledge and belief. So help me God.
________________________________________
Signature of Applicant
________________________________________
Printed Name and Title
State of ____________________
)
County of __________________
)
This instrument was acknowledged before me on ___________ by ________________________________.
Seal
________________________________________
Signature of Notary Public
My appointment expires: ________________
Revised 7/14
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