Form Tc-23 - Brine Shrimp Royalty Statement - Utah State Tax Commission
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Utah State Tax Commission
210 N 1950 W • SLC, UT 84134 •
TC-23
Brine Shrimp Royalty
Rev. 2/07
Statement
FEIN / Account Number
Use this number for
Start below this line. Enter your company name and address.
all references
Royalty Period
Report due on or before
Check box if AMENDED and enter correct
ROYALTY PERIOD being amended above.
1.
Gross weight of unprocessed brine shrimp eggs harvested by you during the season.
"Gross Weight" means the raw, wet harvested weight of the unprocessed brine shrimp
1.
lbs.
eggs, and includes biomass and refuse harvested with the brine shrimp eggs.
2.
Total pounds of all unprocessed brine shrimp
2.
eggs harvested during this season by all harvesters.
.0375
3.
Royalty rate
3.
4.
Amount of tax due
00
.
4
(line 1 times line 3)
I declare under the penalties provided by law that to the best of my knowledge this is a true and correct report.
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Authorized Signature
Date
Telephone
Questions may be directed to the Utah State Tax Commission, 210 N 1950 W, SLC, UT 84134-2400; telephone (801) 297-4600.
Please separate coupon from return at perforation and return coupon with payment. Keep return with your records.
Submit return only if you have an address change.
Print Form
Brine Shrimp Royalty Statement — TC-23
TC-23.ai Rev. 3/05
Amount
00
Federal ID Number
Filing Period
Due Date
Paid
Make check or money order payable to the Utah State Tax Commission.
Do not send cash. Do not staple check to this coupon.
UTAH STATE TAX COMMISSION
BRINE SHRIMP ROYALTY STATEMENT
210 N 1950 W
SLC UT
84134-3500
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