Free Applicant Name - Kansas

Addition to Exemption KSA 79-201t Page 1 of 1

Applicant Name: ________________________ Docket No.:_____________________________

Addition to Exemption Application Low Producing Oil Lease K.S.A. 79-201t
1. Enclose a copy of the oil assessment rendition(s) showing monthly production for the year(s) that you are requesting exemption. Does the rendition report any month(s) with zero production? _____ No _____Yes If "yes", for the months with zero production reported, explain the lack of production, i.e. the well(s) was/were shut-in, down for maintenance or simply not producing. ___________________________________________________________________________

2. 3.

___________________________________________________________________________ ___________________________________________________________________________
4. If the well(s) was/were producing for the month(s) with a zero production reported, how many days of the month(s) was/were the well(s) producing? ___________________________________________________________________________ VERIFICATION

I, ________________________________, do solemnly swear or affirm that the information set forth herein is true and correct, to the best of my knowledge and belief. So help me God. ________________________________________ Signature of Applicant ________________________________________ Printed Name and Title State of ____________________ County of __________________ ) )

This instrument was acknowledged before me on ___________ by ________________________________. Seal ________________________________________ Signature of Notary Public

My appointment expires: ________________
Revised 3/08