Form 4201 - Annual Gross Products For Gas Page 7
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12Gross Products Tax Reporting Instructions
State of Wyoming
ANNUAL GROSS PRODUCTS
Department of Revenue
FOR GAS
122 West 25th Street
GROSS MCF CALCULATION. (Take in-kind interest owners skip to
4201
Cheyenne, WY 82002-0110
Section D.)
TAXPAYER INFORMATION
Production Year:
__ __ __ __
Operator ID
Revenue Use Only
Total well-head production. Enter total production recorded at the well head
PRODUCING ASSET
prior to any adjustments or deductions.
Taxpayer
Reporting Group Number
Enter volume that has been lawfully flared or vented pursuant to
Contact Person / Agent
Telephone Number
Reporting Group Name
authorization to vent or flare by the Wyoming Oil and Gas Conservation
Address
Field Name
Commission (WOGCC).
City
State
Zip
County
Enter volume that has been re-injected for re-pressuring or pressure maintenance
into the same field and formation from which it was removed. This volume is
O = Original
O = Operator
A. Form Type:
B. Taxpayer Type:
excluded from the gross product until it is otherwise used or consumed, sold or
A = Amended
T = Take in-Kind Interest Owner
exchanged.
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)
TIK Interest Owner Volume Taken - COMPLETE BY OPERATOR ONLY
TIK Interst Owner Name
TIK Operator ID
Volume Taken
Enter volume consumed to produce crude oil and natural gas
4a)
on the same lease or unit from which it was produced.
4b)
4c)
Enter only a well deduction that has received prior approval
TIK Interest Owner Volume Taken from 4211 MTD
4d)
from the Mineral Tax Division. An explanation must be attached to
Total Take In-Kind Volume - (Line 4a + 4b + 4c + 4d)
4)
4201 if Box 2d is completed.
D. Taxable Value Calculation
Gross Sales Volume of Natural Gas (Line 3 minus Line 4)
5)
Enter total well-head deductions (2a + 2b + 2c + 2d).
Gross Sales Value of Natural Gas (No Plant Products)
6)
7)
Gross Sales Value of Plant Products (Complete Form 4231)
8a Federal Royalty $
8b State Royalty $
8c Tribal Royalty $
8d Processing $
Enter the gross production at the mouth of well (Line 1
minus Line 2).
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
Authorized Signature
Title
Date
Form 4201 Page 3
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