Claim for Allowable Expenditures

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For credit against Security Deposit(s) of Exploration Licences
Submitted to Northern Oil and Gas Branch - Gatineau, QC K1A 0H4
Northern Affairs Organization, Indian and Northern Affairs Canada

(Refer to Guidance Notes on Claiming Allowable Expenditures)


NOTE: All claims for allowable expenditures must be accompanied by a statement under corporate seal issued by an officer of the company or a professional engineer, geologist or geophysicist that the cost statement is true and accurate to the best of his or her knowledge. Claims for Drilling Operations must be accompanied by a cost statement prepared and certified by an external auditor in accordance with audit and professional standards established by the Canadian Institute of Chartered Accountants (CICA).

Exploration Licence No: EL       
(Pursuant to the terms and conditions of Schedule III )

National Energy Board Program ID# or Well Identifier(WID):

Program Activity Dates (yyyy/mm/dd): from to
Program Type:
           


The following required documents are attached to this Claim for Allowable Expenditures:

Total Amount being claimed for the authorized program/well: $

Total Amount and Percentage applicable to this EL: $ / %

Deposit Identifier Number:  NOG
Please attach a schedule when claims are to be applied against multiple deposits.

Applicant Name (Deposit for):
Deposit Amount $
Deposit Type:    

The Representative hereby declares that the information contained or incorporated herein is true, accurate and complete.

Representative (please print): ______________________________________

Signed: ______________________________________

Date: _____________________