Form 04-315 - Notice Of Transfer Of Alaska Oil And Gas Production Tax Credit - State Of Alaska Department Of Revenue

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State of Alaska
Notice Of
Department of Revenue
Transfer of Alaska Oil and Gas Production Tax Credit
Tax Division
550 W 7th Ave Ste 500
Certificate Under AS 43.55.025
Anchorage AK 99501-3566
This form is available online at
Telephone 907.269.6620
Fax 907.269.6644
DEPT USE ONLY
FSN:
A. Name
Federal EIN or SSN
B. Mailing Address
City
State
Zip Code + 4
C. Physical Address of Business
City
State
Zip Code + 4
D. Contact Person, for examination of records.
Title
Telephone Number
Facsimile Number
E. Production Tax Credit Certificate Number transferred
F. Tax Credit Amount:$_________________
(credit amount on original certificate)
G. Name of Purchaser/Transferee
Federal EIN or SSN
H. Mailing Address
City
State
Zip Code + 4
I. Physical Address of Business
City
State
Zip Code + 4
J. Contact Person, for examination of records
Title
Telephone Number
Facsimile Number
K. Date of Transfer
L. Nature of transfer, attach signed copy of transfer document or sale agreement:
(sale, exchange, other, etc.)
M. Amount received for sale or transfer of production tax credit certificate:
$
N. Amount of tax credit transferred:
$
O. Amount of tax credit retained by seller/transferor:
$
P. Amount of tax credit used by seller/transferor against production taxes:
$
(attach copies of form 04-320 filed by seller/transferor)
I declare under penalty of perjury that this application and each attachment has been examined by me and to the best of my knowledge and belief is
true, correct and complete.
Signature
Type or Print Name and Title
Date
DEPT USE ONLY
Web Form 04-315 (New 02/04)

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