Form Tc-5 - Amended Report - 2003

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TC-5 REV. 6/03
AMENDED REPORT
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TAXPAYER
REPORT PERIOD ENDING
UTAH ACCOUNT NUMBER
DUE DATE:
QUARTERLY OIL AND GAS CONSERVATION FEE RETURN
Get forms online - tax.utah.gov
’
Volume
Royalties
Operator/
Producing
Prod.
Product
Amend Entity No.
Type
Reported by
Subject to
Value
Value Subject To Fee
Other
Transported
State
Indian
Federal
+ -
Others
Fee
$
I have reviewed this report and certify the information to be accurate and complete.
$
TOTAL (value subject to fee)
FEE DUE (value X .002)
Authorized Signature
Preparer Name
GRAND TOTAL (fee due all pages)
$
Date
Telephone
FORM TXOGF1

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