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Form Rpd - 41170 - Production Restoration Project Application And Reporting Instructions

RPD - 41170

STATE OF NEW MEXICO - TAXATION AND REVENUE DEPARTMENT

REV. 09/97

Production Restoration Project

Application and Reporting Instructions

(FORM RPD - 41170)

Name of Individual, Firm or Organization

OGRID Number (for Tax Filer)

Contact

Telephone Number

Mailing Address

City

State

Zip Code

Check One:

Well Operator

Working Interest Owner

Purchaser

Multiple tax remitters may apply for Department approval on a single Form RPD-41170 provided ALL information is

completed using the above format.

PUN

PROPERTY NAME

POOL NAME/NUMBER

API NUMBER

PLEASE ATTACH A COPY OF THE OIL CONSERVATION DIVISION'S APPLICATION FOR QUALIFICATION OF

RESTORATION PROJECT AND CERTIFICATION OF APPROVAL.

FOR DEPARTMENT USE ONLY

Certificate of Approval to Use Production Restoration Incentive Tax Exemption

The New Mexico Taxation and Revenue Department is approving the use of the severence tax exemption for the above well completion

based on the information that you have provided. This Department reserves the right to determine compliance with the provisions of the

Natural Gas and Crude Oil Production Incentive Act.

Approval for use of the severance tax exemption begins with sales month_______________________________.

and ends with sales month _________________________.

Please use Special Tax Rate Code _________ on your Form(s) RPD-41132, Oil & Gas Tax Detail, as it applies to the specific well

completion and Production Unit Number listed above.

Approved by

Date

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Form Rpd - 41170 - Production Restoration Project Application And Reporting Instructions