Form 4201 - Annual Gross Products For Gas Page 10
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12Gross Products Tax Reporting Instructions
State of Wyoming
ANNUAL GROSS PRODUCTS
Department of Revenue
FOR GAS
122 West 25th Street
4201
Cheyenne, WY 82002-0110
TAXPAYER INFORMATION
Production Year:
__ __ __ __
Operator ID
Revenue Use Only
PRODUCING ASSET
Taxpayer
Reporting Group Number
Contact Person / Agent
Telephone Number
Reporting Group Name
Address
Field Name
Allowable Type A Transportation is the actual cost of transportation from the
City
State
Zip
County
outlet of the initial dehydrator to the inlet of the main transmission line or main
processing plant.
O = Original
O = Operator
A. Form Type:
B. Taxpayer Type:
A = Amended
T = Take in-Kind Interest Owner
Explanation for Amendment:
When no dehydration is performed, other than within a processing facility, allowable
Type B Transportation is the actual cost of transportation from the inlet to the
transportation related compressor, custody transfer meter, or processing facility,
C. Gross MCF Calculation (Complete by Operator ONLY)
whichever occurs first, to the inlet of the main processing plant or main transmission line.
1)
Total Well-Head Production
If no dehydration is performed in the field and there is no transportation related
2a Flared/Blown MCF
2b Re-injection MCF
2c Field Use MCF
2d Other MCF
compressor or custody transfer meter there is no Type B Transportation deduction.
2)
Total Well-Head Deductions (Line 2a + 2b + 2c + 2d)
3)
Gross Production at Mouth (Line 1 minus Line 2)
Allowable Type C Transportation is the actual cost of transportation from the inlet of the
TIK Interest Owner Volume Taken - COMPLETE BY OPERATOR ONLY
main transmission line or outlet of the main processing plant to market, where transportation
TIK Interst Owner Name
TIK Operator ID
Volume Taken
is included in the price.
4a)
4b)
Enter the total transportation deduction (Type A + Type B + Type C). NOTE: TYPE A
4c)
TRANSPORTATION PLUS TYPE B TRANSPORTATION CANNOT EXCEED 50
TIK Interest Owner Volume Taken from 4211 MTD
4d)
PERCENT OF THE GROSS SALES VALUE (LINE 6 AND/OR LINE 7) WITHOUT
Total Take In-Kind Volume - (Line 4a + 4b + 4c + 4d)
4)
APPROVAL OF THE DEPARTMENT (WS 39-14-203(b)(xi)).
D. Taxable Value Calculation
Enter Total Deductions (8a + 8b + 8c + 8d + 8e).
Gross Sales Volume of Natural Gas (Line 3 minus Line 4)
5)
Gross Sales Value of Natural Gas (No Plant Products)
6)
Enter Taxable Value (Line 6 plus Line 7 minus Line 8).
Gross Sales Value of Plant Products (Complete Form 4231)
7)
8a Federal Royalty $
8b State Royalty $
8c Tribal Royalty $
8d Processing $
Type A Transportation
Type B Transportation
Type C Transportation
8e)
Total Transportation Deductions
8)
Total Deductions (8a + 8b + 8c + 8d + 8e)
Taxable Value - (Line 6 plus Line 7 minus Line 8)
9)
I declare under penalty of perjury that I have examined this return, and , to the best of my knowledge and belief, it is correct and complete.
MTS2
Authorized Signature
Title
Date
Form 4201 Page 6
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