Form 62a384-O - Oil Property Tax Return Lease Report

62A384-O (1-11)

OIL PROPERTY TAX RETURN

File by April 15 with:

Commonwealth of Kentucky

Department of Revenue

LEASE REPORT

DEPARTMENT OF REVENUE

Offi ce of Property Valuation

For Assessment of January 1, ________

501 High Street, Station 33

Frankfort, Kentucky 40620

Name

(502) 564-8334

Number and Street

Social Security Number

Property located in ____________________________________ County, Kentucky.

__ __ __ __ __ __ __ __ __

City

State ZIP Code

Telephone Number

Federal Identifi cation Number

__ __ __ __ __ __ __ __ __

(

)

INSTRUCTIONS: Under Kentucky law (KRS 132.820) each property owner is required to report all taxable property which he or she owns. This includes sub-surface mineral rights which are taxable as an interest in real

property. This return is provided for the purpose of reporting developed oil property. Each year all persons, corporations, businesses and partnerships owning, leasing or having knowledge of developed oil properties in the

Commonwealth of Kentucky must complete and fi le this tax return with the Offi ce of Property Valuation by April 15. File a separate return for each developed property per county. If the division of ownership is different for

each well on the property, fi le a separate tax return for each individual well. Each lease must be listed separately by the purchaser’s lease number and name. Do not report leases under a grouped unit number.

As a producer/operator, do you want to receive all the tax bills for your working interest owners?

Yes

No

If No, Complete Division of Ownership required (See Reverse Schedule).

Number of Producing Wells

Purchaser’s/Transporter’s Name (if different from fi ler)

Operator’s Name (if different from fi ler)

Purchaser’s Lease Number

Barrels of Oil Produced (Jan. 1–Dec. 31)

Year of First

Waterfl ood

Production

Allowance

(not reporting year)

Credit( )

Purchaser’s Lease Name

Total $ Value of Production for Lease

(Less Severance Tax)

DECLARATION

I declare, under the penalties of perjury, that this return (including any accompanying schedules and statements) has been examined by me and to the best of my knowledge and belief is a true, correct and complete return.

_______________________________________________________

________________________________________

_______________________________________________

___________________________________

Name of Company

Signature of Preparer

Signature of Producer/Operator

Date

Filings received after April 15 will be treated as omitted with applicable penalties applied.