Form 0405-331.1 - Alaska Oil And Gas Production Tax Credit Application For A Transferable Tax Credit Certificate Page 3

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State of Alaska
Application For Transfer of
Department of Revenue
Alaska Oil and Gas Production Tax Credit Certificate AS
Tax Division
43.55.023(d)
550 W 7th Ave Ste 500
Anchorage AK 99501-3566
Phone 907.269.6620
Fax 907.269.6644
This form is available online at
DEPT USE ONLY
APP ID:
A. Producer or Explorer Name
Federal EIN
B. Mailing Address
City
State
Zip Code + 4
C. Physical Address of Business
City
State
Zip Code + 4
D. Contact Person for Examination of Records
Title
Phone Number
Fax Number
Contact Email Address
E. Production Tax Credit Certificate Number to be Transferred
F. Tax Credit Amount (credit amount on original certificate)
(or attach form 0405-331.1 for a New Certificate)
$_______________________________
G. Name of Purchaser/Transferee
Federal EIN
H. Mailing Address
City
State
Zip Code + 4
I. Physical Address of Business
City
State
Zip Code + 4
J. Contact Person for Examination of Records
Title
Phone Number
Fax Number
Contact Email Address
K. Date of Transfer
L. Nature of transfer (sale, exchange, other, etc.). Attach signed copy of transfer
document or sale agreement.
M. Amount received for sale or transfer of production tax credit certificate
$
N. Amount of tax credit transferred
$
O. Amount of tax credit retained by seller/transferor
$
P. Amount of tax credit used by seller/transferor against production taxes
$
(attach copies of Form 0405-330.9, Schedule D for AS 43.55.023 filed by seller/transferor)
I certify, under oath, that the expenditures for which the credit is claimed have been incurred, that the credit has not been used,
and that I am aware of no reason why I do not qualify for the credit.
Signature
Print Name and Title
Date
DEPT USE ONLY
Form 0405-331.2 web new 03/09 • page 2

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