Form 3195-2
(November 2018)
ATTN: Assistant Field Manager for Operations
801 S. Fillmore, Suite 500
Amarillo, Texas 79101
Reners’ Annual Tolling Report
OMB Control No.: 1004-0179
Expires: October 31, 2021
FISCAL YEAR: : Submit annually by October 15 of each year
Volumes in million scf/yr
Date Tolling
Signed Volume
(Per MCF) Delivery Period
Voluntary Disclosure: (1) Tolling agreements for less than 15 million standard cubic feet of helium; and (2) Efforts to reach
tolling agreements that did not result in an agreement (please discuss any offers or efforts through the reporting year to enter tolling
agreements, include attachments as needed):
I certify that the information provided above accurately describes the tolling agreements with non-rener storage contract holders in the
Federal Helium Program required by law to be disclosed and agreements voluntarily disclosed. I understand that this information will be
treated as business sensitive by the BLM, but will be aggregated with other reners’ data for the BLM’s purposes.
Company Name: Title:
Telephone: Printed Name of Authorized Agent:
Email: Signature: Date:
(Continued on Page 2)
(Form 3195-2)
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(Form 3195-2, Page 2)
PAPERWORK REDUCTION ACT (PRA) STATEMENT: The PRA (44 U.S.C. 3501-3521) requires us to inform you that we collect
this information to obtain documentation of rened helium deliveries. The BLM uses this information to monitor compliance with a
statutory requirement that sellers of rened helium to federal agencies buy an equivalent amount of crude federal helium. Responses
are required to obtain or retain a benet (43 CFR 3195 and 50 U.S.C. 167d(b)(8)). In order to ensure the condentiality of information
submitted on this form, the BLM will aggregate the information obtained and disclose it publicly only in the aggregate. You do not have
to respond to this or any other Federal agency-sponsored information collection unless it displays a currently valid OMB control number.
The public reporting burden for this form is estimated to be 4 hours per response, including the time for reviewing instructions, gathering
and maintaining data, and completing and reviewing the form. You may send direct comments regarding the burden estimate or any other
aspect of this form to the U.S. Department of the Interior, Bureau of Land Management (1004-0179), 1849 C Street, NW, Room 2134LM,
Attention: Bureau Information Collection Clearance Ofcer (WO-630), Washington, DC 20240.