Form D Mining Lease Bond

OMB Control No. 1076-0180

Expiration Date xx/xx/xxxx

Form D

UNITED STATES

DEPARTMENT OF THE INTERIOR

BUREAU OF INDIAN AFFAIRS

OSAGE MINING LEASES BOND

KNOW ALL MEN BY THESE PRESENT, That we,

­­­­­­­­­­­ of _____,

as principal , and

of as surety , are held and firmly bound unto the United States of America in the sum of_________ Dollars, lawful money of the United States, for the payment of which, well and truly to be made, we bind ourselves, and each of us, our and each of our heirs, successors, executors, administrators, and assigns, jointly and severally, firmly by these present.

Sealed with our seals and dated this day of , 20 ­­­­­­­­

The condition of this obligation is such that whereas the said

, principal, as lessee, entered into certain indenture of lease, dated ___________________ with the Osage Tribe of Indians, lessor, for the lease of a tract of land described as follows:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ and located in Osage County, Oklahoma, for (oil) (gas) mining purposes for a period of five years from the date of approval hereof, and as long thereafter as (oil) (gas) is found in paying quantities, provided that the term of this lease shall not extend beyond the date when the title to the minerals ceases to be in the Osage Tribe:

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

WHEREAS the surety hereby waives any right to notice of any modification of such lease or obligation thereunder, whether effected by extension of time for performance, by commitment of such lease to unit, cooperative, or communitization agreement, by waiver, suspension, or change in rental, except an increase thereof, by minimum royalty payment, except an increase thereof, by compensatory royalty payment, or otherwise, this bond to remain in full force and effect notwithstanding.

WHEREAS the principal and surety agree that the neglect or forbearance of the oblige-lessor in enforcing the payment of any rental or royalty or the performance of any other covenant, condition, or agreement of the lease, shall not, in any way release the principal and surety, or either of them, from any liability under this bond; and

WHEREAS the principal and surety agree that in the event of any default under such lease, the oblige-lessor may commence and prosecute any claim, suit, action, or other proceeding against the principal or surety, or either of them, without the necessity of joining the other.

Now, if the said principal herein shall faithfully carry out and observe all the obligations assumed in said indenture and leases to which he, she or it, is now or may hereafter become a party and shall observe all the laws of the United States and regulations made, or which shall be made, thereunder, for the government of trade and intercourse with Indian tribes and all the rules and regulations that have been, or shall hereafter be, lawfully prescribed by the Secretary of the Interior to such oil mining leases and to the development thereof, and shall in all particulars comply with the provisions of said leases, rules, and regulations, then this obligation shall be null and void; otherwise to remain in full force and effect.

The rate of premium charged on this bond is $ ___; the total premium paid is $

Signed and sealed in the presence of -

WITNESSES: (Two witnesses to all signatures)

P. O. as to (SEAL)

P. O.

P. O. as to (SEAL)

P. O.

P.O.

P. O. as to (SEAL)

Surety Agent_________________________Address:_____________________________________________________

DEPARTMENT OF THE INTERIOR

BUREAU OF INDIAN AFFAIRS

OSAGE AGENCY

PAWHUSKA, OKLAHOMA

The within bond is hereby approved pursuant to authority delegated by 25 CFR 226.9

Approved:

Under authority delegated by: 209 DM 8, 230 DM

1, 3 IAM 4.1 and Muskogee Area Addendum 9901

to 3 IAM 4 issued June 22, 1999.

Superintendent

Paperwork Reduction Act Statement: We are collecting this information subject to the Paperwork Reduction Act (44 U.S.C. 3501) to ensure resources to address contingencies and well shut down in protection of trust resource. Your response is voluntary and we will not share the results publicly. We may not conduct or sponsor and you are not required to respond to a collection of information unless it displays a currently valid OMB Control Number. OMB has reviewed and approved this survey and assigned OMB Control Number 1076-0180, which expires ##/##/####.

Estimated Burden Statement: We estimate the form will take you 1 hour to complete, including time to read instructions, gather information, and complete and submit the form. You may submit comments on any aspect of this information collection to the Information Collection Clearance Officer, Office of Regulatory Affairs & Collaborative Action—Indian Affairs (RACA), U.S. Department of the Interior, 1001 Indian School Road NW, Suite 229, Albuquerque, NM 87104.