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PROPERTY SCHEDULE FOR GAS AND OIL WELL ASSESSMENT
State Form 9931 (R5 / 1-09)

March 1, 20 ______ FORM G & O-1
The records in this series are confidential according to IC 6-1.1-35-9.

Prescribed by Department of Local Government Finance

PRIVACY NOTICE

INSTRUCTIONS: 1. File separate schedule for each gas and oil lease. 2. The form is to be filed with the Assessor not later than May 15 of each year. 3. Gas and oil interests are assessable per IC 6-1.1-4-12.4 and IC 6-1.1-4-12.6. SECTION 1
Name Address (number and street, city, state, and ZIP code) (Check one) Contact person Title of contact person

TAXPAYER INFORMATION
Telephone number

(

)

Owner SECTION 2
Location Lease

Operator LEASE INFORMATION
County Legal description Township Section Township DLGF taxing district number Range Acres

Check if the well is an oil well using secondary recovery method. Also check if the well stimulates oil production by means of injection of water, steam, hydrocarbons, or chemicals, or by in situ combustion. (IC 6-1.1-4-12.6) SECTION 3 A. B. C. D. E. F. G. H. I. FACTORS FOR BASIS OF ASSESSMENT 3A. 3B. 3C. 3D. 3E. 3F. 3G. 3H. 3I. Per MCF or barrels

Price per unit of gas or oil on assessment date (per DLGF) Average daily production of gas or oil Annual production value (multiply 3A. by 3B. by 365) Enter 0.5 if secondary recovery method in use Enter 1.0 if initial recovery method Interest in gas or oil rights (multiply 3C. by 3D.) Appurtenances - enter number of producing wells Enter value of single well appurtenance (per DLGF) Total value of appurtenances (multiply 3F. by 3G.)

0.00

0.00

0.00

Total basis of working interest assessment (Sum 3E. and 3H. and enter here and in 5A.) SECTION 4 COMPUTATION OF ROYALTY INTEREST ASSESSMENT 4A. 4B. 4C.

0.00

A. B. C. D.

Interest in gas or oil rights (from 3E.) Basis for royalty assessment (multiply 4A. by 1.50) Enter royalty interest factor (for example, 0.1250 for 1/8 interest)

0.00

0.00

Total royalty interest assessment subject to allocation on page 2 (multiply 4B. by 4C.) SECTION 5 COMPUTATION OF WORKING INTEREST ASSESSMENT 5A. 5B.

4D.

0.00

A. B. C.

Total basis of working interest assessment (from line 3I.) Enter total royalty interest assessment (from 4D.) Working interest factor

0.00
0.00
5C.

Working interest assessment (subtract 5A. minus 5B.)

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INSTRUCTIONS FOR ALLOCATION OF INTERESTS: 1. Enter in Column 1 an R for a royalty interest or a W for a working interest. 2. Enter in Column 2 the decimal equivalent for the interest in the entire property (for example, 0.1250 for a 1/8 royalty interest). The entries in this column should total 1.0000. 3. Enter in Column 3 the decimal equivalent of the partial interest in the particular interest noted in Column 2 (for example, 0.5000 for a 1/2 interest in the 1/8 royalty interest). The entries in this column for a particular interest type (R or W) should total 1.0000. 4. Multiply the interest in Column 3 by the respective assessment subject to allocation and enter the result in Column 4. Note the sum of the entries should equal the sum of 4D. and 5C. FORM G & O-1 ALLOCATION OF ROYALTY AND WORKING INTEREST ASSESSMENTS COLUMN 1
INTEREST TYPE (R or W)

ASSESSMENT SUBJECT TO ALLOCATION (enter from page 1) Royalty interest (4D.) Working interest (5C.) OWNER ADDRESS ( number and street, city, state, and ZIP code)

COLUMN 2
INTEREST FACTOR IN PROPERTY

COLUMN 3
INTEREST FACTOR WITHIN TYPE

COLUMN 4
CALCULATED ASSESSMENT

ACKNOWLEDGMENT AND CERTIFICATION Under the penalties of perjury, I hereby certify that this schedule to the best of my knowledge and belief is true, correct and complete; and reports the production and well information under this lease.
Signature Address (number and street, city, state, and ZIP code) Printed name (type or print) Date signed (month, day, year)

NOTARY STATE OF : COUNTY OF:

Before me, a notary public in and for said state and county, personally appeared, this ___________day of _________________________, 20 ________, the owner/operator or a person duly authorized to sign for and on behalf of said lessee, who acknowledged the execution of this return as the voluntary act and deed of the owner/operator.
Signature of Notary Name of Notary (type or print) County of residence Date commission expires (month, day, year)

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