Form Ow-12 - Withholding For Nonresident Royalty Interest

Form Number OW-12

Oklahoma Tax Commission (OTC)

Revised 11-2001

2501 Lincoln Boulevard

Oklahoma City, OK 73194-0010

Office Use

Withholding for Nonresident Royalty Interest

Withholding for Nonresident Royalty Interest

Withholding for Nonresident Royalty Interest

Withholding for Nonresident Royalty Interest

Withholding for Nonresident Royalty Interest

1. How is business owned?

(a) Individual

(b) General Partnership

(c) Limited Partnership

Approval ____________________

(d) Oklahoma Corporation

(e) Foreign Corporation

(f) Limited Liability Company (LICO)

Denied _____________________

(g) other (explain) ___________________________________________________________________

Status

2.

3. ( ________ ) ________ - _____________

FR

WH

Federal Employer’s Identification Number (FEIN)

Business Phone (Area Code & No.)

Ownership Information

Ownership Information

Ownership Information

Ownership Information

Ownership Information

4.

__________________________________________________________________________________________________

Name of Individual, Partnership or Corporation

Social Security Number (If Individual)

___________________________________________________________________________________________________

Mailing address (Street and number, P.O. Box, or rural route and box number)

___________________________________________________________________________________________________

City

State

ZIP Code

County

5.

Names. of Partners, Corporate Officers, and Managing Officer:

(a) ______________________________________________________________________________________________

Name (Last, First, Middle Initial)

Social Security Number

Title

___________________________________________________________________________________________________

Mailing address (Street and number, P.O. Box, or rural route and box number)

___________________________________________________________________________________________________

City

State

ZIP Code

County

(b)______________________________________________________________________________________________

Name (Last, First, Middle Initial)

Social Security Number

Title

___________________________________________________________________________________________________

Mailing address (Street and number, P.O. Box, or rural route and box number)

___________________________________________________________________________________________________

City

State

ZIP Code

County

(c)______________________________________________________________________________________________

Name (Last, First, Middle Initial)

Social Security Number

Title

___________________________________________________________________________________________________

Mailing address (Street and number, P.O. Box, or rural route and box number)

___________________________________________________________________________________________________

City

State

ZIP Code

County

(If you need more space, attach additional pages.)

6. Date you began/will begin withholding for nonresident royalty interest?.....................(month/day/year)_______/________/_______

7. What FEI number will you use to report withholding tax?(If different than item 2)..................

8.

___________________________________________________________________________________________________

Trade Name of Business - DBA

9.

___________________________________________________________________________________________________

Physical Location (Street and number or directions; not P.O. Box or Rural Route Number)

City

State

ZIP

County

10. ___________________________________________________________________________________________________

Name and title of officer or employee responsible for remitting withholding for nonresident royalty interest

Phone Number

11. ___________________________________________________________________________________________________

Address to which forms are to be mailed

City

State

ZIP Code

A sole owner; general partner; corporate officer; or authorized representative must sign this application.

I, the undersigned applicant or authorized representative, declare under the penalties of perjury that I have examined this application and attachments and to the best of my knowledge the facts set forth are true and

correct, and that the requirements hereunder will be carried out in accordance with the laws of the State of Oklahoma and the rules and regulations of the Oklahoma Tax Commission. I further acknowledge and agree

that sales, withholding, and motor fuel taxes are trust funds for the State of Oklahoma and that any use of these trust funds other than timely remittance to the State of Oklahoma is embezzlement and can result in

sign

criminal prosecution.

here

Type or print name and title

Signature

Date

Mandatory inclusion of Social Security and/or Federal Employer’s Identification numbers is required on forms filed with the Oklahoma Tax Commission pursuant to Title 68 of the Oklahoma Statutes and regulations

thereunder, for identification purposes, and are deemed part of the confidential files and records of the Oklahoma Tax Commission. The Oklahoma Tax Commission is not required to give actual notice of changes in

any state tax law.