DEFERRED REBATE APPLICATION 328-DR E-Mail: firstname.lastname@example.org GPX OPERATOR FEI/SSN OPERATOR NAME COMPANY REPORTING NUMBER WELL NAME PRODUCTION UNIT NUMBER - - - CHECK ONE: ULTRA DEEP WELL HORIZONTALLY DRILLED Tax Remitter Product Production Period Net Net GP Tax Rebate Rebate Reporting # Code Month Year Volume Value Paid Percentage Amount TYPE OF REPORT (2) Total Rebate Claimed $0.00 Submitted by: Date: Telephone Number: If submitted by an entity other than the operator, provide the following: Name Address City State ZIP Please check one: Filing as an interest owner Filing as representative of operator GENERAL INSTRUCTIONS PURPOSE - This application is to be used to apply for the refund of Gross Production Tax paid on approved horizontal and ultra deep wells for the production periods of July through June 2010 and 2011. No other types of rebates may be claimed on this form. This application shall only be submitted via e-mail to the following address: email@example.com WHO IS ELIGIBLE TO APPLY – An operator or a designee who is approved by the operator to file on behalf of all participating interest owners. DATE APPLICATION IS TO BE SUBMITTED – Complete fiscal years shall be filed no later than December 31st, 2011. INSTRUCTIONS FOR PREPARING FORM 328-DR OPERATOR FEI/SSN: Enter the operator/working interest owner’s FEI or social security number. OPERATOR NAME: Enter the well operator name. COMPANY REPORTING NUMBER: Enter the operator/working interest owner’s number assigned by the Oklahoma Corporation Commission. WELL NAME: Enter the well name as registered on OTC form 320. PRODUCTION UNIT NUMBER: Enter the production unit number assigned to the well by OTC Form 320-A. (List one production unit number per page). CHECK ONE: Check appropriate box for which the well qualifies - ULTRA DEEP WELL or HORIZONTAL WELL. TAX REMITTER REPORTING NUMBER: Enter the tax remitter’s assigned company reporting number. PRODUCT CODE: Enter the code representing the product upon which GP Tax was paid. Product codes shall be shown as one of the following: Code 1 = Oil, Code 5 = Natural Gas, Code 6 = Natural Gas Liquids. Only one (1) product per page may be claimed. PRODUCTION PERIOD: Enter month and year of product being produced (List one month per line). NET VOLUME: Enter the net volume attributable to the well after approved deductions. GP TAX PAID: Enter the amount of GP Tax remitted for the product produced for the specified production month. The remaining fields will be automatically calculated to reflect the amount of rebate due for the given production month and a sum total of all months totaled at the bottom of the rebate amount column.