DEPARTMENT OF TAXATION
1550 EAST COLLEGE PARKWAY SUITE 115
CARSON CITY, NEVADA 89706
NET PROCEEDS OF MINERALS, ROYALTIES RECEIVED
CALENDAR YEAR 199-
PURSUANT TO NRS 362.110: STATEMENT MUST BE POSTMARKED BY FEB. 1, 199- TO AVOID
LATE FILING PENALTIES.
«INCAREOF»
«NAME»
«ADDRESS»
«CITY»
Re: «COUNTY»
«MINENAME»
(A separate report must be filed for each mine, oil well, or geothermal project)
PLEASE CORRECT ABOVE INFORMATION WHERE NECESSARY
PRODUCTION ROYALTIES RECEIVED FROM:
MONTHLY PRODUCTION
ROYALTIES ACTUALLY
NAME AND ADDRESS
RECEIVED
_____________________________________________________
01-9-
$__
_______________
________
_____________________________________________________
02-9-
$__________
_______
________
_____________________________________________________
03-9-
$_________________________
_____________________________________________________
04-9-
$_________________________
_____________________________________________________
05-9-
$_________________________
_____________________________________________________
06-9-
$_________________________
_____________________________________________________
07-9-
$_________________________
_____________________________________________________
08-9-
$_________________________
_____________________________________________________
09-9-
$_________________________
_____________________________________________________
10-9-
$_________________________
_____________________________________________________
11-9-
$_________________________
_____________________________________________________
12-9-
$_________________________
TOTAL.
…………………………
………
……………
$_________________________
…………..
..
…
I hereby certify to the best of my knowledge and belief that the foregoing is a full and true statement of total
royalties received for the calendar year 199- for the above-named mine.
_________________
___________________________________________
Date
Signature