Form 0405-156 - Alaska Oil And Gas Production Tax Annual Return - Tax Summary Form - 2010

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State of Alaska
Department of Revenue
Alaska Oil and Gas Production Tax Annual Return
Tax Division
AS 43.55
550 W 7th Ave Ste 500
Tax Summary Form
Anchorage AK 99501-3566
Telephone 907.269.6620
Tax Year
Fax 907.269.6644
2010
Dept Use Only
A. Taxpayer
Federal EIN or SSN
B. Mailing Address
City
State
Zip Code + 4
C. Physical Address of Business
City
State
Zip Code + 4
D. Contact Person, for examination of records
Title
Telephone Number
Email Address
Check if Yes:______
E. Original Return?
F. Amended Return?
Check if Yes:_____________
Amendment No.
G. Reason for amendment:
H. Annual Tax Summary:
Annual Production Tax levied by AS 43.55.011(e) after tax limitations:
AMOUNT
1. North Slope, excluding gas used in state
2. North Slope, gas used in state
3. Non-N. Slope, non-Cook Inlet, excluding gas used in state
4. Non-N. Slope, non-Cook Inlet, gas used in state
5. Cook Inlet Oil, all segments
6. Cook Inlet Gas, all segments
7. Subtotal, lines 1 - 6
$
-
8. Landowner's Royalty Interest Production Tax levied by AS 43.55.011(i):
9. Annual Total Production Tax Liability, line 7 plus line 8
$
-
10. Sum of estimated monthly payments, excluding credits
11. Sum of tax credits applied in estimated monthly payments
12. Total tax paid in estimated monthly payments, line 10 plus line 11
$
-
13. Net tax due (owed), Line 9 less Line 12
$
-
14. Interest due (owed) from monthly installment payments
15. Interest paid
16. Net interest due or (owed) from under- or overpayment of monthly installment payments,
line 14 less line 15
$
-
17.
Production Tax Due (owed), line 13, plus line 16
$
-
18. Conservation surcharge levied by AS 43.55.201
19. Conservation surcharge levied by AS 43.55.300
20. Total surcharges, line 18 plus line 19
$
-
21. Total surcharges paid
22. Net surcharges due (owed), line 20 less line 21
$
-
23. Interest on surcharges due, if paid after March 31, 2011
24. Additional interest due with return, if paid after March 31, 2011
25. Remittance due, with this return, or refund owed,
line 17 plus line 22 plus line 23 plus line 24
$
-
26. Amount paid, with this return
27. OTIS Tracking Number for amount paid on Line 26:
Declaration: I declare under penalty of perjury that this return and each attachment has been examined by me and to the best of my knowledge and belief is true, correct
and complete.
Signature
Type or Print Name and Title
Date
DEPT USE ONLY
Form 0405-156 (New 03/11)
This form is available on the Tax Division Website at:
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