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Utah State Tax Commission
TC-684
Oil & Gas Severance Tax
Rev. 6/04
Annual Return
210 North 1950 West - Salt Lake City - Utah 84134 - (801) 297-2200
Get forms online - tax.utah.gov
Tax year
Name and address
Due date
Account number
Check this box if AMENDED return
and enter the correct TAX YEAR
being amended
00
1. TOTAL OIL & GAS TAXABLE VALUE at 3% (Total from all Schedule A, Line 20)
$
00
2. TOTAL OIL & GAS TAXABLE VALUE at 5% (Total from all Schedule A, Line 21)
00
3. TOTAL NGL TAXABLE VALUE at 4% (Total from all Schedule A, Line 22)
00
4. TOTAL INCREMENTAL TAXABLE VALUE (Total from all Schedule A, Line 23)
00
5. TOTAL TAXABLE VALUE (add lines 1 through 4)
$
00
6. OIL & GAS TAXES at 3% (multiply line 1 by .03)
$
00
7. OIL & GAS TAXES at 5% (multiply line 2 by .05)
$
8. NGL TAXES at 4% (multiply line 3 by .04)
00
$
00
00
9. INCREMENTAL TAXES at .015 and/or .025 or .02 (multiply line 4 by rate)
$
00
10. TOTAL TAX LIABILITY (add lines 6 through 9)
$
11. INSTALLMENTS/CREDIT (if applicable)
$
00
a. CREDIT (carried forward from line 15 of previous years return)
00
b. FIRST QUARTER INSTALLMENT
$
00
c. SECOND QUARTER INSTALLMENT
$
00
d. THIRD QUARTER INSTALLMENT
$
00
e. FOURTH QUARTER INSTALLMENT
$
$
00
12. TOTAL INSTALLMENTS/CREDIT (add lines 11a through 11e)
00
$
13. TAX (subtract line 12 from line 10)
$
14. WORKOVER OR RECOMPLETION CREDIT (attach Schedule B)
00
Check box if you want credit
00
$
15. TAX DUE or (CREDIT) (subtract line 14 from line 13)
carried over to next year
Penalties and interest will be computed as provided by law and billed by the Utah State Tax Commission for late filing and/or late
payment. I have reviewed this report and certify the information to be accurate and complete.
Authorized Signature
Date Signed Telephone number
X