Form Mt-03 Monthly Natural Gas Well Report
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1
2Registrants ID #
Purchaser
KANSAS DEPARTMENT OF REVENUE
Operator
DIVISION OF TAXATION
(Check one only)
MINERAL TAX
Taxpayer Name and Mailing Address
TOPEKA, KANSAS 66625-0918
NATURAL GAS PRIOR PERIOD ADJUSTMENT
Preparers Telephone # _____ / _____ - _______
Page _____ of _____
Column 10
Column 1 Well
Column 3 Gross
Column 4 Gross
Column 5 K.C.C
Column 6 Exempt
Column 8 Taxable
Column 9 Taxable
Column 11 Adj.
Column 2 Well Name
Column 7 Cert. #
Severance Tax
Code
MCF’s (Volume)
Vaule
Assessment
MCF’s
MCF’s (Volume)
Value
Month/Year
Liability
$
$
$
$
$
$
$
$
$
PAGE TOTALS
MT-03a
(Rev. 10/07)
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