Form Onrr-2014 - Report Of Sales And Royalty Remittance

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U.S. DEPARTMENT OF THE INTERIOR
OMB Control Number 1012-0004
REPORT OF SALES AND ROYALTY REMITTANCE
Office of Natural Resources Revenue
OMB Approval Expires 3/31/2019
FORM
-2014
1
PAYOR NAME: _____________________________________
3
FEDERAL/INDIAN REPORT INDICATOR
(F or I)
2
4 PAYOR-ASSIGNED
PAYOR CODE: __ __ __ __ __
DOCUMENT NUMBER __ __ __ __ __ __ __ __
For ONRR Use Only
5
6
7
10
11
12
13
14
15
16
17
18
23
INTENTIONALLY
RESERVED FOR
ONRR
SALES VOLUME
GAS MMBtu
SALES VALUE
LEFT
PREPARER’S USE
LEASE NUMBER
(Mcf/bbl/gal/long ton)
$
BLANK
8
9
19
20
21
22
ROYALTY VALUE
MMS
TRANSPORTATION
PROCESSING
ROYALTY VALUE
PRIOR TO ALLOWANCES
API WELL NUMBER
AGREEMENT NUMBER
ALLOWANCE
ALLOWANCE
LESS ALLOWANCES
$
DEDUCTION $
DEDUCTION $
$
1
2
3
4
PAGE
TOTAL
I have read and examined the statements in this report and agree they are accurate and complete.
Checks To ONRR (PM1)
________________
REPORT
*Indian Direct Pay (PM2)
________________
TOTAL
Authorized Name (print) and Signature
Date
EFT Payments (PM3)
________________
*Royalty-In-Kind (PM4)
________________
If company contact information has changed, please indicate below: (Please print)
Checks To ONRR For BIA (PM5)
________________
Other (For Future Use) (PM6)
________________
Contact Name
Phone Number
*Indian Lockbox (PM7)
________________
Total All Payments:
________________
=
Street
P.O. Box
Suite or Other Identifier
Less Available Credits:
(*Credits may not be applied to PM2, PM4, PM7)
Doc. ID: _________________
_______________
-
City
State
Zip Code
Doc. ID: _________________
________________
-
Doc. ID: _________________
________________
-
PAGE ____ OF _____
Net Payment for this Report:
= $
________________
Email Address
Fax Number
Form ONRR-2014 (revised 12/2009)

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