Form 317-R-93 - Affidavit For Occ Credit And/or Otc Tax Exclusion printable pdf download

Form 317-R-93 - Affidavit For Occ Credit And/or Otc Tax Exclusion

See Reverse

317-R-93

Side For

AFFIDAVIT FOR OCC CREDIT AND/OR OTC TAX EXCLUSION

Instructions

Distribution

NOTE: This affidavit may be used for obtaining credit on allowables, (O.C.C. Rule 165:10-13-6) and Tax Exclusion from

Gross Production Taxes, (O.T.C. Rule 710:45-9-10).

1 THROUGH 4 TO BE COMPLETED BY OPERATOR

OTC Assigned

(1) LOAD OR FRAC OIL DELIVERED TO:

Operator

Reporting No.

Address:

Zip

Lease Name:

Legal Description:

Sec

Twp

Rge

O.T.C. Assigned Production Unit Number:

Pool:

Allocated

Unallocated

Formation

Depth:

Load or Frac Oil to be allocated to various purchasers--

Yes

Companies sharing allocation:

Date Load or Frac Oil Puchased or Transferred:

(2) LOAD OR FRAC OIL OBTAINED FROM:

Refinery

Lease

Other

Company or Lease Operator Name:

Operator's Reporting Number:

OTC Assigned Production Unit Number:

Legal Description:

Sec

Twp

Rge

Lease Name:

Pool Name:

Load or Frac Oil Volume:

Load or Frac Oil Value:

NOTE: Please attach invoice or bill of sale showing value paid for load or frac oil, if lease from which load or frac oil was

obtained cannot be identified.

(3) GROSS PRODUCTION TAXES PAID ON INJECTED LOAD OR FRAC OIL

Tax Paid on

Volume $

Value in

Production Month

Taxpaying Company:

Company Reporting Number:

(4) I, the undersigned, swear (or affirm) that the information set out above is true and correct and the amount of oil purchased,

indicated in part two (2) was used and injected into the well named in part one (1) of this instrument.

Signature

Title

Subscribed and sworn before me, a Notary Public in and for said County and State this

day of

County

State

Notary

My Commission Expires:

5 AND 6 TO BE COMPLETED BY TAXPAYER TAKING LOAD OR FRAC OIL EXCLUSION

Date

Volume

Value

(5)

Total Load or Frac Oil Injected (as shown above)

Load or Frac Oil Recovered

Load or Frac Oil Remaining to be Recovered

(If additional space is needed, attach separate schedule).

(6) I, the undersigned, swear (or affirm) that the information set out in 5 above is true and correct.