Form 4201 - Annual Gross Products For Gas Page 8
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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
OPERATOR WHO IS DEDUCTING PRODUCTION TAKEN IN-KIND ONLY: itemize
Address
Field Name
each interest owner taking production in-kind who is reporting on their own behalf and the
City
State
Zip
County
volume taken. Accurately enter the TIK interest owner’s name and Operator ID. If the
Operator ID is unknown, contact the Mineral Tax Division. If there are more than three
interest owners taking production in-kind who are reporting on their own behalf, complete
O = Original
O = Operator
A. Form Type:
B. Taxpayer Type:
and attach 4211.
A = Amended
T = Take in-Kind Interest Owner
Explanation for Amendment:
Operator Only: enter total volume taken in-kind from
C. Gross MCF Calculation (Complete by Operator ONLY)
4211 if any.
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
4a)
4b)
4c)
4d)
TIK Interest Owner Volume Taken from 4211 MTD
Total Take In-Kind Volume - (Line 4a + 4b + 4c + 4d)
4)
D. Taxable Value Calculation
5)
Gross Sales Volume of Natural Gas (Line 3 minus Line 4)
6)
Gross Sales Value of Natural Gas (No Plant Products)
Gross Sales Value of Plant Products (Complete Form 4231)
7)
Operator Only: enter the total volume taken in-
8a Federal Royalty $
8b State Royalty $
8c Tribal Royalty $
8d Processing $
kind, (4a+4b+4c+4d).
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 4
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