Form 10-170 - Amended Crude Oil Tax - 2003
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1
210-170
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(Rev.9-09/3)
b.
36110
a.
Page ______ of ______
SEE INSTRUCTIONS.
c. Taxpayer number
d. Filing period
Amended CRUDE OIL Tax
-- PURCHASER 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. Producer's name
3. Producer'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. Producer's
10. Producer's
taxpayer number
taxpayer number
YES
NO
YES
NO
1
2
1
2
11. Are you liable for tax?
11. Are you liable for tax?
If "NO" in Item 11, complete
If "NO" in Item 11, complete
only Items 12, 13 and 16 below.
only Items 12, 13 and 16 below.
12. API gravity
12. API gravity
Enter adjusted data in Items 13 - 19.
Enter adjusted data in Items 13 - 19.
13. Gross barrels
13. Gross barrels
(Enter whole barrels)
(Enter whole barrels)
14. Governmental
14. Governmental
royalty barrels
royalty barrels
(Enter whole barrels)
(Enter whole barrels)
15. Taxable barrels
15. Taxable barrels
(Enter whole barrels)
(Enter whole barrels)
$
$
16. Gross value
16. Gross value
(Dollars and cents)
(Dollars and cents)
17. Governmental
17. Governmental
$
$
royalty value
royalty value
(Dollars and cents)
(Dollars and cents)
$
$
18. Trucking costs
18. Trucking costs
(Dollars and cents)
(Dollars and cents)
$
$
19. Net taxable value
19. Net taxable value
(Dollars and cents)
(Dollars and cents)
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