Form 4201 - Annual Gross Products For Gas Page 11
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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
City
State
Zip
County
O = Original
O = Operator
A. Form Type:
B. Taxpayer Type:
A = Amended
T = Take in-Kind Interest Owner
Explanation for Amendment:
C. Gross MCF Calculation (Complete by Operator ONLY)
1)
Total Well-Head Production
2a Flared/Blown MCF
2b Re-injection MCF
2c Field Use MCF
2d Other MCF
2)
Total Well-Head Deductions (Line 2a + 2b + 2c + 2d)
3)
Gross Production at Mouth (Line 1 minus Line 2)
Form 4201 for the 2001 Production Year is due by February 25, 2002.
TIK Interest Owner Volume Taken - COMPLETE BY OPERATOR ONLY
TIK Interst Owner Name
TIK Operator ID
Volume Taken
4a)
Mail completed forms to:
Wyoming Department of Revenue
4b)
Mineral Tax Division
4c)
th
122 West 25
Street
TIK Interest Owner Volume Taken from 4211 MTD
4d)
Cheyenne WY 82002-0110
Total Take In-Kind Volume - (Line 4a + 4b + 4c + 4d)
4)
D. Taxable Value Calculation
All paper forms must be signed and dated originals, faxed returns will not be accepted.
5)
Gross Sales Volume of Natural Gas (Line 3 minus Line 4)
Gross Sales Value of Natural Gas (No Plant Products)
6)
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
Total Deductions (8a + 8b + 8c + 8d + 8e)
8)
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
12/16/99
Authorized Signature
Title
Date
Form 4201 Page 7
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