Form 10-172 - Amended Crude Oil Tax - 2003
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210-172
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(Rev.9-09/3)
b.
48110
a.
Page ______ of ______
SEE INSTRUCTIONS.
c. Taxpayer number
d. Filing period
Amended CRUDE OIL Tax
-- PRODUCER Lease Detail Supplement --
f.
e. Taxpayer name
LOCATOR NUMBER
LOCATOR NUMBER
1. Lease name (as recorded with the Railroad Commission)
1. Lease name (as recorded with the Railroad Commission)
2. County of production
2. County of production
3. Purchaser's name
3. Purchaser's name
4. County code
4. County code
Check
Check
digit
digit
5. Lease number
5. Lease number
YES
NO
YES
NO
1
2
1
2
6. Is Item 5 a drilling permit number?
6. Is Item 5 a drilling permit number?
7. Exempt type
7. Exempt type
(If applicable)
(If applicable)
8. API number
8. API number
(If applicable)
(If applicable)
Baseline
Incremental
Baseline
Incremental
9. Incremental exemption
9. Incremental exemption
1
2
1
2
(If applicable)
(If applicable)
10. Purchaser's
10. Purchaser's
taxpayer number
taxpayer number
YES
NO
YES
NO
1
2
1
2
11. Are you the lease operator?
11. Are you the lease operator?
YES
NO
YES
NO
1
2
1
2
12. Are you liable for tax?
12. Are you liable for tax?
If "NO" in Item 12, complete only
If "NO" in Item 12, complete only
Items 13, 14 and 17 below.
Items 13, 14 and 17 below.
13. API gravity
13. API gravity
Enter adjusted data in Items 14 - 20.
Enter adjusted data in Items 14 - 20.
14. Gross barrels
14. Gross barrels
(Enter whole barrels)
(Enter whole barrels)
15. Governmental
15. Governmental
royalty barrels
royalty barrels
(Enter whole barrels)
(Enter whole barrels)
16. Taxable barrels
16. Taxable barrels
(Enter whole barrels)
(Enter whole barrels)
$
$
17. Gross value
17. Gross value
(Dollars and cents)
(Dollars and cents)
18. Governmental
18. Governmental
$
$
royalty value
royalty value
(Dollars and cents)
(Dollars and cents)
$
$
19. Trucking costs
19. Trucking costs
(Dollars and cents)
(Dollars and cents)
$
$
20. Net taxable value
20. Net taxable value
(Dollars and cents)
(Dollars and cents)
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