Form Tc-684a - Severance Tax Annual Return - Schedule A

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Severance Tax Annual Return - Schedule A
Page ___ of ___ Pages
TC-684A Rev. 11/04
Taxpayer's name
Utah account number
AMENDED REPORT
Address
Tax year
First
Operator
purchaser
City
Field number
Field name
Interest
Other: _______
owner
Field
GRAND Total
Total
(all pages)
1. Amended + -
2. Producing entity no.
Get forms online
3. Product type
tax.utah.gov
4. Transported
DO NOT
WRITE
5. Reported by others
IN THIS AREA
Subject to tax
6.
(line 4 - line 5)
7. Gross product value
8. Processing deduction
9. Transportation deduction
Net product value
10.
(line 7 - lines 8 & 9)
11. Exempt royalties
Adjusted value
12.
(line 10 - line 11)
Annual (field) Exemption
13.
Percentage
Annual Exemption (line 13 x
Percent Basis for Annual
14.
Exemption x $50,000
Taxable net value amount
15.
(line 12 - line 14)
16. Stripper production value
First six months
17.
development well value
First twelve months
18.
wildcat well value
Taxable amount
19.
(Subtract lines 16, 17, 18
from line 15)
20. Taxable value at 3%
21. Taxable value at 5%
22. NGL taxable value at 4%
Incremental tax value (Oil &
23.
Gas at 1.5%, Oil & Gas at
2.5%, and NGL at 2%)
Percent Basis
Basis for Annual (field) Exemption (divide total of Line 12 by Line 10)
Use this percentage when completing Line 14.

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