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Form Ogp-D - 2015 Annual Report Of Non-Resident Remittees Holding An Agreement To Pay Tax On Oil And Gas Proceeds Page 2

New Mexico Taxation and Revenue Department

*154090200*

2015 Annual Report of Non-Resident

Remittees Holding an Agreement to Pay

Tax on Oil and Gas Proceeds

Supplemental Page

Remitter’s FEIN or SSN

Remitter’s name

Check one:

FEIN

Page _______ of _______

SSN

Remittee’s name,

Column 2

Column 3

Column 4

street address,

Remittee’s SSN or FEIN

Remittee’s oil and

Tax withheld and

city, state, and ZIP code

gas proceeds

paid by the remitter

Mark one:

FEIN

Mark if outside the U.S.

SSN

Mark one:

FEIN

Mark if outside the U.S.

SSN

Mark one:

FEIN

Mark if outside the U.S.

SSN

Mark one:

FEIN

Mark if outside the U.S.

SSN

Mark one:

FEIN

Mark if outside the U.S.

SSN

Mark one:

FEIN

Mark if outside the U.S.

SSN

Mark one:

FEIN

Mark if outside the U.S.

SSN

Mark one:

FEIN

Mark if outside the U.S.

SSN

If you need more space, print this supplemental page directly from

Line 2. Total withholding on this page.

the website and attach the additional supplemental pages to the

first page of this report. Reproducing from a photocopy reduces

the readability of the bar code on scanning equipment.

OGP-D

Form Ogp-D - 2015 Annual Report Of Non-Resident Remittees Holding An Agreement To Pay Tax On Oil And Gas Proceeds Page 2

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