Form 10-175 - Texas Crude Oil Tax Amended - 2003

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10-175
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(Rev.9-09/3)
b.
48130
a.
Page ______ of ______
SEE INSTRUCTIONS ON BACK.
c. Taxpayer number
d. Filing period
Texas CRUDE OIL Tax AMENDED
-- Producer SPECIAL Lease Detail Supplement --
f.
e. Taxpayer name
LOCATOR NUMBER
LOCATOR NUMBER
HP
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. Lease operator indicator
11. Lease operator indicator
YES
YES
1
1
12. Are you liable for tax?
12. Are you liable for tax?
13. API gravity
13. API gravity
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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