Mtd Form 3 - Well Status Notification And Grouping Request - 2000

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MTD FORM 3
Rev 1/00
WELL STATUS NOTIFICATION AND GROUPING REQUEST
Complete for each well whenever there is a new well, a change in the well operator, or a change in well status. Complete this form to request reporting group
assignment for each well.
Section 1: Taxpayer Information
Company Name:
Contact Person:
Address:
City:
State:
Zip:
Phone Number:
Operator ID Number:
Section 2: Purpose of Report
A. Change of Operator
Complete Sections
1, 2, 3, 4, 5, 6
B. Change of Well Status
Complete Sections
1, 2, 3, 4, 5
C. New Well - New Group
Complete Sections
1, 2, 3
D. New Well - Addition to Existing Group
Complete Sections
1, 2, 3, 4
E. Existing Well Group Reassignment
Complete Sections
1, 2, 3, 4
F. Register as a Take in-kind interest owner
Complete Sections
1, 2, 3, 4
Section 3: Well Description
Complete API #
(as assigned by the Oil and
___ ___ ___
___ ___ ___ ___ ___
___ ___
___ ___ ___
0
4
9
_
_ _
_ _
_
Gas Conservation Commission)
Side Track
State
County
Well
Reservoir
Legal Description: Lot & Tract
____ 1/4 ___
1/4 ___
Sec
___
Twn
____ Rng _____
Well Name:
____________________________ Field Name:
_________________________________
Exempt Royalty:
Federal
____ State ____ Tribal ____ None
____
Well Type:
Oil ____ Gas
____
Initial Production Date:
______________
Section 4: Group Assignment
Current Group Number
:
__ __ __ __ __
(as assigned by the Mineral Tax Division)
New Requested Group Assignment
:
__ __ __ __ __
(reassignment requests only)
Take In-Kind Interest Owners - Effective Date:
________________ Product(s) Taken: ____________
Section 5: Well Status
AI - Active Injection PR - Producing SI - Shut In
Well Status:
_____
Effective Date:
________________
PA - Plugged & Abandoned TA - Temporarily Abandoned
1
Section 6: Change of Operator
New Operator
Previous Operator
Name:
Name:
__________________________________
_________________________________
Contact:
Contact:
_________________________________
________________________________
Addr:
Addr:
__________________________________
_________________________________
__________________________________
_________________________________
__________________________________
_________________________________
Operator ID:
____________
Operator ID:
____________
1
New Operator Effective Date
:
_____________________
(per Wyoming Oil & Gas)
Signed:
__________________________________
Date:
_________________________
Return To: Wyoming Department of Revenue - Mineral Tax Division - 122 W 25th Street - Cheyenne, WY 82002-0110

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