Form 5400 - Severance Tax Report For Sand & Gravel - 1999 Page 2
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1
2State of Wyoming
SEVERANCE TAX REPORT
5400
Department of Revenue
122 West 25th Street
*5400*
SAND & GRAVEL
Cheyenne WY 82002-0110
DOR USE ONLY:
Operator ID:
Taxpayer Name:
O - Original
Prod Period:
Form Type:
A - Amended
REPORTING
TONS SOLD AND
SALES VALUE
TONS MINED
TOTAL TAXABLE
TOTAL TAX DUE
PREVIOUS TAX PAID
TAX DUE
NUMBER
USED
VALUE
(AMENDS)
PAGE TOTAL:
REV. 5/19/99
PAYMENT AMOUNT:
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.
Authorized Signature
Title
Date
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