Form Tc-684a - Schedule A - Severance Tax Annual Return
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1Severance Tax Annual Return - Schedule A
Page ___ of ___ Pages
TC-684A Rev. 7/97
Taxpayer's name
Utah account number
AMENDED REPORT
`
`
Address
Tax year
First
Operator
`
purchaser
City
Field number
Field name
Interest
Other: ____
`
owner
Field
GRAND Total
`
`
`
`
`
`
Total
(all page)
1. Amended + -
2. Producing entity no.
DO NOT
3. Product type
WRITE
IN THIS AREA
4. Transported
5. Reported by others
Subject to tax
6.
(llne 4 - line 5)
7a. Product value
O
O
O
O
O
O
O
O
Unit value
7b.
(information only)
8. Exempt royalties
Adjusted value
9.
(Line 7a - Line 8)
O
O
O
O
O
O
O
O
Annual (field) Exemption
10.
Percenatge
Annual Exemption (line 10 x
11.
Percent Basis for Annual
Exemption x $50,000
Taxable net value amount
12.
(line 9 - line 11)
13. Stripper production value
First six months
14.
development well value
First twelve months
15.
wildcat well value
Taxable amount
16.
(Subtract line 13, 14, 15
from line 12)
17. Taxable value at 3%
18. Taxable value at 5%
19. NGL taxable value at 4%
Incremental tax value (Oil &
20.
Gas at 1.5%, Oil & Gas at
2.5%, and NGL at 2%)
Percent Basis
Basis for Annual (field) Exemption (divide total of Line 9 by Line 7a)
684A.frm
Use this percentage when completing Line 11.
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