Form 328-R-10-97 - Gross Production 841/495 Refund Application

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328-R-10-97
GPX
G
P
841/495 R
A
ROSS
RODUCTION
EFUND
PPLICATION
3. PAGE [
] OF [
] PAGES
2. CHECK ONE
OKLAHOMA TAX COMMISSION
[
] INACTIVE WELL
GROSS PRODUCTION SECTION
1.
A. OPERATOR FEI/SSN
TYPE OF REPORT
[
] WORKOVER/RECOMPLETED WELL
P.O. BOX 53423
[2]
[
] DEEP WELL
OKLAHOMA CITY, OKLAHOMA 73152-3423
B. OPERATOR NAME
[
] NEW DISCOVERY WELL
[
] ECONOMICALLY AT RISK
C. COMPANY REPORTING NUMBER
2. B. OCC/OTC APPROVAL NUMBER
[
] HORIZONTALLY DRILLED
4 .
5 .
6 .
7 .
8 .
9 .
1 0 .
1 1 .
1 2 .
1 3 .
1 4 .
1 5 .
TAX REMITTERS
PRODUCTION
NUMBER
GROSS
GROSS
VOLUME OF
8 4 1
8 4 1
GROSS
PRODUCTION
PRODUCTION
REPORTING
PERIOD
OF WELLS
VOLUME
VALUE
BASE
EXEMPT
EXEMPT
PRODUCTION
UNIT NUMBER
NUMBER
CODE
MONTH
YEAR WELL NAME
ON LEASE
OF WELL
OF WELL
PRODUCTION
VOLUME
VALUE
TAX REFUND
TOTAL
1 6 .
I, the undersigned, swear (or affirm) that the information set out above is true and correct.
Signature
Subscribed and sworn before me, a Notary Public in and for said County and State this
date of
,
.
County
State
Notary Public
My Commission Expires:

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