Form Mmn-3 - Statement Of Net Proceeds Of Mines Vermiculite Producers Only
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1
2MONTANA
MMN-3
Rev. 12-07
Statement of Net Proceeds of Mines
Vermiculite Producers Only
For Year Ending December 31, 20 ____
Title 15, Chapter 23, Part 5, MCA
Name:
Address:
Address:
City:
State:
Zip Code:
1. FEIN:
2. Account ID:
3. Period:
4. If this is an amended return, check here.
5. If you are no longer in business and want your account cancelled, check this box
, enter the fi nal date. __________
6. If your mailing address has changed, check this box
and print new address below:
____________________________________________________________________
____________________________________________________________________
Name of Mine:
County:
Section:
Township:
Range:
School District:
7. Total tons of Vermiculite extracted ........................................................................................ 7.
8. Vermiclite value per ton ........................................................................................................ 8. $
9. Taxable Value (line 7 X line 8) .............................................................................................. 9. $
Schedule of Royalty Interests
Name
Address
Amount
$
$
$
$
Returns are due on March 31st of the following year. Penalties and Interest apply on all delinquent reports pursuant to
15-23-104, MCA.
I hereby swear or affi rm under penalty of perjury that the statements contained herein are true to the best of my
knowledge.
Signature ___________________________________________
Title _______________________________________________ Phone __________________ Date ________________
Mail this return to:
Department of Revenue, PO Box 5805, Helena MT 59604-5805
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