MMS-2014 Report of Sales and Royalty Remittance

Attachment 3

OMB Control Number 1010-0140
OMB Approval Expires 10/31/2006

REPORT OF SALES AND ROYALTY REMITTANCE
FORM MMS-2014

1 PAYOR NAME: _____________________________________
4 PAYOR-ASSIGNED
DOCUMENT NUMBER __ __ __ __ __ __ __ __

9

8
API WELL NUMBER

MMS
AGREEMENT NUMBER

12

13

14

TRANSACTION
CODE

MMS
LEASE NUMBER

11

SALES
MO/YR

RESERVED FOR
PREPARER’S USE

10

SALES
TYPE CODE

7

PRODUCT
CODE

LINE NUMBER

6

ADJUSTMENT
REASON CODE

2 PAYOR CODE: __ __ __ __ __
5

For
MMS
Use
Only

(F or I)

3 FEDERAL/INDIAN REPORT INDICATOR

15

17

16
SALES VOLUME
(mcf/bbls/gal/long tons)

19

PAGE ____ OF _____

GAS MMBtu
SALES VOLUME

ROYALTY VALUE
PRIOR TO ALLOWANCES
$

20

TRANSPORTATION
ALLOWANCE
DEDUCTION $

18
ROYALTY
RATE

21

PROCESSING
ALLOWANCE
DEDUCTION $

23
UNIT PRICE
$

22

ROYALTY VALUE
LESS ALLOWANCES
$

PAYMENT
METHOD CODE

U.S. Department of the Interior
Minerals Management Service
Minerals Revenue Management

1

2

3

4
I have read and examined the statements in this report and agree they are accurate and complete.

Date

If company contact information has changed, please indicate below: (Please print)

Contact Name

FORM MMS-2014 (revised 03/2006)

Phone Number

Street

P.O. Box

Suite or other Identifier

City

State

Zip Code

FAX Number

E-mail Address

PAYMENT INFORMATION

Authorized Name (print) and Signature

PAGE TOTAL

Report Total:
Less:
Indian Direct Pay (PM2) Amount
Indian Lockbox (PM3) Amount
Royalty-In-Kind (PM4) Amount
Other (PM5) Amount
Amount Due MMS (PM1):
Less Available Credits:
Doc. ID: ________________
Doc. ID: ________________
Doc. ID: ________________
Net Payment for this Report:

_________________
$
_________________
_________________
_________________
_________________
_________________
$
_________________
_________________
_________________
_________________
$