Form Ap-180 - Request For Approval Of Reduced Tax Rate For High Cost Gas

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AP-180

PRINT FORM

CLEAR FORM

(Rev.6-13/7)

Request for Approval of Reduced

You have certain rights under Chapters 552 and 559, Government Code,

to review, request and correct information we have on file about you.

Tax Rate for High Cost Gas

• Do not write in shaded areas.

• See instructions on back of form.

00990

1126

T Code

Taxpayer name, contact person and mailing address

Complete this form and mail to:

Comptroller of Public Accounts

P.O. Box 13528

Austin, TX 78711-3528

If you have any questions about this form,

please call 1-800-252-1384 or 512-463-4600.

Texas taxpayer number

In accordance with Tax Code, Section 201.057(h), drilling and completion costs included on this form are confidential and

may not be disclosed, except to the extent aggregated with other similar information to produce industry averages.

Texas Railroad Commission (RRC) Lease Information

Lease name

Name of RRC field in which well is located

Total measured well depth

True vertical well depth

API number

County of production

County code

RRC lease number

Is well indicated above a multiple completion well? ....................................................................................................................

YES

Was this well designated by RRC as a Statewide Rule Exception (SWR-10)? ...........................................................................

YES

Dates

Well spud date (year and month)

Well completion date (year and month)

RRC approval date (mm/dd/yyyy)

First date of production (year and month)

High Cost Gas Production Information

High cost gas was produced as a result of (check one):

designated tight formation

completion below 15,000 feet