Application To Deposit Cash In Lieu Of Surety Bond - Form 3D.3

Application to Deposit Cash in lieu of Surety Bond - Form 3.D.3 Department of Mineral Resources Oil and Gas Division 600 E Boulevard Ave Dept 474 Bismark N.D 58505 to 0614 S.F.N 54259 (08 to 2026)

Field: N.D.I.C Bond Number

Please read instructions before filling out form. Please submit the original .

Field: Applicant

Field: Telephone Number

Field: Address

Field: City

Field: State

Field: Zip Code

The applicant proposes to set up a cash bond in the amount of (select only one):

Checkbox option: $50,000 bond (covers 1 well)

Checkbox option: Covers 1 treating plant or 1 saltwater handling facility

Checkbox option: $100,000 bond (covers 2 or more wells)

Checkbox option: Abandoned well bond (covers 1 well)

Checkbox option: $100,000 bond for commercial injection (covers 1 well)

Checkbox option: Other bond for

The applicant proposes to drill and/or operate wells, as listed below:

Field: Well or Plant File Number

Field: Well or Plan Name and Number

Field: Location (Qtr-Qtr, S-T-R)

Field: Current Operator

Is the applicant currently the operator of any other wells located in the state of North Dakota?

Checkbox option: Yes

Checkbox option: No

I hereby swear or affirm that the information provided is true, complete and correct as determined from all available records

Field: Signature

Field: Printed Name

Field: Title

Field: State of

Field: County of

Signed and sworn to (or affirmed) before me this

Field: Date

Field: Name of Individual Making Statement

Field: Affix Notary Stamp

Field: Signature of Notary Public or Other Authorized Officer

Field: Commission Expiration Date

1. In order to file a cash bond, you must first contact the Department of Mineral Resources, Oil and Gas Division

2. Please refer to Section 43-02-03-15 of the North Dakota Administrative Code regarding bonds.

3. Name of applicant shall be the name of the operator and shall be the same as reported on the Organization Report - Form 2 (S.F.N 5748).

4. The well or plant file numbers, well or plant names and numbers, locations, and current operators shall coincide with the official records on file with the Department.

5. If additional space is necessary, please attach additional sheet(s) including the well file number, well name and number, location by quarter-quarter, section, township, and range, and the current operator.

6. The original of this report shall be filed with the Department of Mineral Resources, Oil and Gas Division, 600 E Boulevard Ave, Dept 474, Bismarck N.D 58505 to 0614.