Form Tc-5 - Utah Quarterly Oil And Gas Conservation Oil Fee Return, Tc-5

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TC-5 REV. 4/04
Clear form
Get forms online - tax.utah.gov
AMENDED REPORT
REPORT PERIOD ENDING
TAXPAYER
UTAH ACCOUNT NUMBER
DUE DATE:
QUARTERLY OIL AND GAS CONSERVATION FEE RETURN
Round all volumes and values to whole numbers.
Volume
Royalties
Processing/
Operator/
Producing Prod.
Product
Adjusted
Transportation
Amend
Reported by
Subject to
Value Subject
Other
Entity No. Type
Value
Deduction
Product
Transported
State
Indian
Federal
+ -
(attach detail
To Fee
Others
Fee
Value
schedule)
$
I have reviewed this report and certify the information to be accurate and complete.
$
TOTAL (value subject to fee)
FEE DUE (value X .002)
Authorized Signature
Preparer Name
GRAND TOTAL (fee due all pages)
$
Date
Telephone
FORM TXOGF1

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