Form Sv 5 - Additional Taxes On Coal

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SV 5
Reset Form
Rev. 5/13
P .O. Box 530
Columbus, OH 43216-0530
Additional Taxes on Coal
Name
Account No.
Address
Period
(A)
(B)
(C)
(D)
(E)
Permit Number
Location Name
Total Quantity Extracted
Reclamation Quantity
Surface Mining
(Tons)
As assigned by the Ohio Department
If the permitted location has posted a
If the permitted location is mined using
of Natural Resources
performance security adequate to cover
surface mining methods, enter the quantity
the cost of reclamation, enter -0-;
extracted below. If not, enter -0-.
otherwise enter the quantity extracted below
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
0
0
0
Subtotal:
Transfer Column (C) subtotal
Transfer Column (D) subtotal
Transfer Column (E) subtotal
to line 1 of the SV3.
to line 1A of the SV3.
to line 1B of the SV3.
Use additional pages as needed.
Page __ of __

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