Form Dor Form 82063 - Property Tax Form - Oil, Gas And Geothermal Interests Page 2

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CONFIDENTIAL
WELL IDENTIFICATION
Producer:
Address:
City:
State:
Well Name:
Field:
County:
School District #:
Other Districts:
Legal description of well location:
PRODUCTION REPORT FOR THE YEAR 2012
Oil, Gas and
Helium
Other
Total
Geothermal
Crude Oil
Natural
(MCF)
Specify
Gross
Production
(BBL)
Gas-(MCF)
Raw Gas
(BBL or MCF)
Yield
Cumulative
Prod. for Year
Exempt Amt.
Total Used
on Lease
Gross
Production
Total Sales
$
$
$
$
$
of Product
Average Sales
$
$
$
$
$
Price
$
$
$
$
$
Gross Yield
Exempt amounts and amounts used on lease must be explained fully and must conform with provisions of
42-14101, Arizona Revised Statutes (See "Gross Production" definition, page 3 of this report).
If necessary, attach additional copies of this page to the report.
OWNERSHIP
(All columns must be completed, including total)
Name and Address
Decimal Interest
Gross Yield
Working Interest
Royalty, Interest, including Overriding Royalty
$
(Specify Ownership and Type)
$
Total (Excludes Amount Used on Lease)
DOR Form 82063 (Revised 11-12)
Page 2 of 4

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