State Form 9931 - Property Schedule For Oil And Gas Well Assessment - 2001
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1
2PROPERTY SCHEDULE FOR OIL AND
Assessment date
G and O
Form 1
GAS WELL ASSESSMENT
March 1, 20 ______
State Form 9931 (R3 / 10-01)
Prescribed by Department of Local Government Finance
IC 6-1.1-4-12.4 and 12.5
PRIVACY NOTICE: The records in this series are confidential according to I.C. 6-1.1-35-9, 1982 edition.
INSTRUCTIONS: File separate schedule for each lease annually by May 15 with township assessor.
Name
Address (number and street, city, state, ZIP code)
Lease
Township
(Check one)
County
Owner
Operator
Section
Township
Range
Acres
Legal description
I. COMPUTATION OF FACTORS
A. OIL IN STORAGE
X $
X .65
= $
(A)
Bbl. of oil on hand
Price of oil per bbl.
Carry to 11A
B. INTERESTS IN OIL OR GAS
X $
X 365 (X 1/2 for Secondary
= $
(B)
RecoveryifApplicable)
Avg. daily production
Price of oil per bbl. or
Carry to 11B
- (Check if Secondary)
gas per MCF
C. APPURTENANCES
X $
= $
(C)
Number of producing wells
Per well value of
appurtenances
TOTAL OF (A) + (B) + (C)
= $
(D)
II. COMPUTATION OF BASIS FOR ASSESSMENT OF ROYALTY INTERESTS
A. OIL IN STORAGE
(E)
[from (A)]
= $
B. INTERESTS IN OIL OR GAS $
X 1.50
(F)
from (B)
(G)
= $
BASIS FOR ROYALTY ASSESSMENT (E) + (F)
Carry to III A
III. COMPUTATION OF WORKING AND ROYALTY INTEREST ASSESSMENT
(H)
= $
=
X $
A. 1.00000-.
Net Working Interest
Royalty Interest
from (G)
Total Royalty Interest
Assessment
(i)
= $
BASIS FOR WORKING INTEREST ASSESSMENT (D) - (H)
Total Working Interest
Assessment
(Continued on reverse side)
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