Form Mt-07 - Initial Oil Exemption Request (Minimum Production Or Water Flood)

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OFFICE USE ONLY EXEMPTION STATUS

Retaining this Exemption request:

KANSAS DEPARTMENT OF REVENUE

Exemption Approved: ____ Yes ____ No

DIVISION OF TAX OPERATIONS

Operator/Purchaser(s) should retain

MINERAL TAX

Approved Exemption No.: ________________

a certified/approved copy of this

915 SW HARRISON ST

Effective Date: _________________________

TOPEKA KS 66625-0918

application. (K.S.A. 79-4224)

PHONE: 785-296-7713

FAX: 785-296-4993

Termination Date: ______________________

INITIAL OIL EXEMPTION REQUEST

(MINIMUM PRODUCTION OR WATER FLOOD)

Application is hereby made to the Director of Taxation to exempt the following lease or well from Kansas Mineral Tax. Application is made with full

knowledge of the penalties as prescribed by law. See instructions on page 2 of this form. Return 3 copies of this completed form to the address above.

Operator Name and Address

Operator Email Address

Contact Name

Contact Phone Number

LEASE INFORMATION (MANDATORY FOR ALL EXEMPTIONS)

Reason for Exemption (check only one): ______Minimum Production or ______Water Flood

KCC Operator I.D. Number: _________________________ Operator Phone Number: __________________________

Oil Well, Kansas Oil Lease/Well Number: _1_ ___ ___ ___ ___ ___.

Lease Name: ___________________________________________ County Name: _________________________________________

Legal description: Sec. _________________ Twn. __________________ Rng _________________ Average Depth of Producing Wells: _______________

Number of Producing wells on Lease (

Injection wells are not counted as producing wells

): ___________ API Number:

_________________________________*

Name of Producing Formation: _______________________________________________ Field Name: _______________________________________

COMPLETE IF WATER FLOOD OR MINIMUM PRODUCTION EXEMPTION

Average Daily Production is __________ BOPD. This is for the most recent six month period beginning __________________ and ending _________________.

See page 2 of this form for more detail in calculating average daily production and current exemption levels.

Do not send this form in if Average Daily Production is above the minimum levels.

If Water Flood Exemption, is production gauged separately? ___ Yes ___ No

If Water Flood Exemption, what is the docket number from the KCC Enhanced Recovery Order? ____________________

COMPLETE IF INCREMENTAL EXEMPTION

The KCC must certify all enhancement projects prior to exemptions being granted. Incremental Exemptions are granted on a well basis only. If Incremental

Exemption, what is the certified KCC enhancement project number? _____________________________________

The Incremental Exemption is valid for 7 years from the KCC certified startup date. KCC certified date is: ___________________________

*See Severance Tax Incentive’s Update at website:

I declare under the penalties of perjury that all the required KCC certifications have been received and this application is true and correct.

Signature of Authorized Officer or Agent

Date

Purchaser Address Information

Print Operator’s & Purchaser’s address

clearly, they will be used as mailing labels.

Purchaser ID #

Purchaser Contact Information

MT-07