Instructions For 4111: Annual Gross Products Take In-Kind Balance Sheet For Oil Page 3
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4Gross Products Tax Reporting Instructions
State of Wyoming
ANNUAL GROSS PRODUCTS
Department of Revenue
TAKE IN-KIND
122 West 25th Street
4111
Cheyenne, WY 82002-0110
BALANCE SHEET FOR OIL
Production Year:
__ __ __ __
TAXPAYER INFORMATION
PRODUCING ASSET
Operator ID
Revenue Use Only
Reporting Group Number
Calendar year in which production occurred.
Taxpayer
Reporting Group Name
B. Take In-Kind Interest Owner Volume Information
TIK Interest Owner Name
TIK Operator ID
Volume Taken
Taxpayer’s Operator ID as assigned by the Wyoming Oil and Gas
Reporting Group Name
Conservation Commission (WOGCC), or as assigned by the
Mineral Tax Division.
The Reporting Group
Number assigned by the
Taxpayer’s name. Do not enter an agent’s name here.
Mineral Tax Division
Enter the volume taken.
Enter the name of each take in-kind interest owner who is
reporting on their own behalf
Enter the Operator ID of each take in-kind interest owner.
Contact the Mineral Tax Division if the Operator ID is
unknown.
COMPLETE FORM 4111 AND
Enter the total volume taken here and on Form 4101
ATTACH TO FORM 4101 IF THERE
Section D Line 5d.
ARE MORE THAN THREE
INTEREST OWNERS TAKING
PRODUCTION IN-KIND.
Page Total
(Enter here and on 4101, Section D, Line 5d)
I declare under penalty of perjury that I have examined this return, and , to the best of my knowledge and belief, it is correct and complete.
MTS2
12/16/99
Authorized Signature
Title
Date
Form 4111 page 1
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