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             PROPERTY SCHEDULE FOR GAS AND OIL WELL ASSESSMENT                                                                               January 1, ______ 
             State Form 9931 (R12 / 1-2 )3                                                                                                   FORM G & O-1 
             Prescribed by the Department of Local Government Finance 
                                                                                                                                             PRIVACY NOTICE 
                                                                                                                                 The records in this series are confidential; 
                                                                                                                                 however, an oil or gas interest listed on the 
INSTRUCTIONS:                                                                                                                    delinquent property tax list may be disclosed 
                                                                                                                                 to the public according to IC 6-1.1-35-9(g). 
1. File separate schedule for each gas and oil lease.
2. The form is to be filed with the appropriate township or county assessor not later than May 15.
3. Pursuant to IC 6-1.1-4-12.6, failure to file this form on or before May 15 will result in a $25 penalty and an additional 10% penalty for failure to file this form within    thirty
   (30) days after the May 15 due date.
4. Gas and oil interests are assessable per IC 6-1.1-4-12.4 and IC 6-1.1-4-12.6.

SECTION 1                                                              TAXPAYER INFORMATION 
Name of Taxpayer                                                                   Telephone Number 
                                                                                   (           ) 
Address (number and street, city, state, and ZIP code) 

(Check One)                         Contact Person 
☐     Owner       ☐     Operator
Title of Contact Person                                                            Email Address of Contact Person

SECTION 2                                                                  LEASE INFORMATION 
Location                                   County                                  Township                                      DLGF Taxing District Number 

Lease                                      Section                                 Range                                         Acres 

Legal Description 

☐     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 means of in situ combustion. (IC 6-1.1-4-12.6)

   SECTION 3                                                    FACTORS FOR BASIS OF ASSESSMENT 
A.    Price Per Unit of Gas or Oil on Assessment Date (per DLGF)                          3A.                                    Per MCF or barrels 
B.    Average Daily Production of Gas or Oil                                              3B. 
C.    Annual Production Value (multiply Line 3A by Line 3B by 365)                        3C. 
D.    Enter 0.5 if Secondary Recovery Method In Use                                       3D. 
      Enter 1.0 if Initial Recovery Method 
E.    Interest in Gas or Oil Rights (multiply Line 3C by Line 3D)                                                                3E. 
F.    Appurtenances – Enter Number of Wells                                               3F. 
G.    Enter Value of Single Well Appurtenance (per DLGF)                                  3G. 
H.    Total Value of Appurtenance (multiply Line 3F by Line 3G)                                                                  3H. 
I.    Total Basis of Working Interest Assessment (Sum Line 3E and Line 3H and enter here and on Line 5A)                         3I. 

   SECTION 4                                           COMPUTATION OF ROYALTY INTEREST ASSESSMENT 
A.    Interest in Gas or Oil Rights (from Line 3E)                                        4A. 
B.    Basis for Royalty Assessment (multiply Line 4A by 1.50)                             4B. 
C.    Enter Royalty Interest Factor (for example, 0.1250 for 1/8 interest)                4C. 
D.    Total Royalty Interest Assessment Subject to Allocation on Page 2 (multiply Line 4B by Line 4C)                            4D. 

   SECTION 5                                           COMPUTATION OF WORKING INTEREST ASSESSMENT 
A.       Total Basis of Working Interest Assessment (from Line 3I)                        5A 
B.       Enter Total Royalty Interest Assessment (from Line 4D)                           5B. 
C.       Working Interest Factor                       Working Interest Assessment (subtract Line 5B from Line 5A)               5C. 

                                                                              Page 1 of 2 

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 ½ 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 Line 4D
and Line 5C.
FORM G & O-1                           ALLOCATION OF ROYALTY AND WORKING INTEREST ASSESSMENTS 
          ASSESSMENT SUBJECT TO ALLOCATION (enter from Page 1)                                  COLUMN        COLUMN             COLUMN      COLUMN 
Royalty Interest (Line 4D) ____________ Working Interest (Line 5C) ____________                 1             2                  3                                         4 
        OWNER                  ADDRESS (number and street, city, state, and ZIP code) INTEREST TYPE       INTEREST FACTOR INTEREST FACTOR    CALCULATED 
                                                                                                (R or W)  IN PROPERTY            WITHIN TYPE 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, complete, and reports the production and well 
information under this lease. 
Signature                                              Printed Name (type or print)                                              Date Signed (month, day, year) 

Address (number and street, city, state, and ZIP code) 

                                                                                    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                                                                   County of Residence 

Name of Notary (type or print)                                                        Date Commission Expires (month, day, year) 

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