Form Rp - 7019 - Oil And Gas Economic Profile Form
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1NEW YORK STATE DEPARTMENT OF TAXATION AND FINANCE
OFFICE OF REAL PROPERTY TAX SERVICES
Oil and Gas Economic Profile Form For the Year Ending December 31, 20___
Producers of more than 1,000 barrels of oil or 200,000 mcf's of gas are required by law to submit this form.
Please fill out all information accurately and completely. Additional information may be attached if necessary.
Section 1: Producer Information
Producer Name: ______________________________
Formation*: ________________________
Address:
______________________________
Average Well Age: __________________
Representative: ______________________________
Average Well Depth: _________________
Phone Number: ______________________________
County: ___________________________
Email address:
______________________________.
Town/City:__________________________
Section 2: Well Type and Royalty Information
Well Type(please check box)
Production Type (for oil wells)
Oil
Stripper wells
Gas
Enhanced recovery wells
Both**
Other
Gas Well Royalties:
Oil Well Royalties:
Land Owner royalties:
$________________
________________%
Land Owner royalties:
$________________
________________%
Overriding royalties
$________________
________________%
Overriding royalties
$________________
________________%
Total royalties
$________________
________________%
Total royalties
$________________
________________%
Section 3: Production and Income Information
Gas Wells
Oil Wells
Total Number of wells reported on this form: ________
Total Number of wells reported on this form: _______
Total Production of wells (Mcf's): _________________
Total Production of wells (barrels): _______________
Total Gross Income:
$_________________
Total Gross Income:
$_________________
Section 4: Expense Information
Gas Wells
Oil Wells
Total operating expenses: (loe's)
$______________
Total operating expenses: (loe's)
$______________
Depreciation:
$_______________
Depreciation:
$_____________
Depletion:
$______________
Depletion:
$______________
Dry Hole Costs:
$______________
Dry Hole Costs:
$______________
Reserve for abondonment
$______________
Reserve for abondonment
$______________
Certification: I, ___________________________, _________________________________, of ______________________________
(name)
(title)
(Company name)
Certify that the above information for the calendar year of 20____ is true to the best of my knowledge and belief.
______________________________________________
____________________________
(Signature)
(Date)
Mail this form to: NYS Department of Taxation and Finance, Office of Real Property Tax Services
Jeremy Kergel, Oil and Gas Unit, Building 8a, W.A. Harriman State Campus, Albany NY 12227
Any questions regarding this form or the program can be directed to Jeremy Kergel at 518-474-1562.
* If drilling in Medina, please indicate which medina region. A breakdown can be found at: ,
or by contacting Jeremy Kergel at 518-474-1562
** If your wells are producing both gas and oil, please make every attempt to separate the expenses, income, and royalty.
RP - 7019 03/2011
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