Form 4201 - Annual Gross Products For Gas Page 6
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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
The Reporting Group Number assigned by
TAXPAYER INFORMATION
Production Year:
__ __ __ __
the Mineral Tax Division
Operator ID
Revenue Use Only
PRODUCING ASSET
Name of the Field where the property is
Taxpayer
Reporting Group Number
located as designated by the Wyoming Oil
and Gas Conservation Commission
Contact Person / Agent
Telephone Number
Reporting Group Name
(WOGCC)
Address
Field Name
Wyoming County where the property is
City
State
Zip
County
located
Reporting Group Name
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)
Enter ‘O’ if you are the operator of
Enter ‘O’ for an original
this property. Enter ‘T’ if you are
3)
Gross Production at Mouth (Line 1 minus Line 2)
report. Enter ‘A’ for an
an interest owner taking
TIK Interest Owner Volume Taken - COMPLETE BY OPERATOR ONLY
amended report
production in-kind on this
TIK Interst Owner Name
TIK Operator ID
Volume Taken
4a)
property
4b)
4c)
For amended reports, list the specific reason(s)
4d)
TIK Interest Owner Volume Taken from 4211 MTD
for the amendment.
Total Take In-Kind Volume - (Line 4a + 4b + 4c + 4d)
4)
D. Taxable Value Calculation
Gross Sales Volume of Natural Gas (Line 3 minus Line 4)
5)
6)
Gross Sales Value of Natural Gas (No Plant Products)
7)
Gross Sales Value of Plant Products (Complete Form 4231)
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)
9)
Taxable Value - (Line 6 plus Line 7 minus Line 8)
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
Form 4201 Page 2
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