Form Dr-142 - Solid Mineral Severance Tax Return

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Mail to:
DR-142
Solid Mineral Severance Tax Return
Florida Department of Revenue
R. 01/13
5050 W Tennessee St
TC
For Year:
Tallahassee Florida 32399-0150
Rule 12B-7.026
Florida Administrative Code
Check here if amending your return
Effective 05/13
DOR USE ONLY
POSTMARK OR HAND-DELIVERY DATE
Certificate #
:
Name
FEIN
:
Address
Taxable Year
:
City/St/ZIP
Return Due By :
Late After
:
Complete Return Schedules First
US DOLLARS
CENTS
Tax Due with Return Calculation
,
,
16. Gross Tax Due:
.................................................................... $
(from Lines 4, 8, and 15)
,
,
17. Payments and Other Credits:
17a. Estimated Tax Payments: ........................................................................... $
,
,
....................................................................... $
17b. Other Credits:
(see instructions)
,
,
18. Total Tax Due: ..................................................................................................... $
,
,
19. Penalty: ............................................................................................................... $
,
,
20. Interest: ............................................................................................................... $
,
,
21. Total Due with Return: ....................................................................................... $
,
,
22. Credit: .................................................................................................................. $
,
,
23. Refund: ............................................................................................................... $
Under penalties of perjury, I declare that I have read the foregoing and the facts stated in it are true.
___________________________________________________________________________________________________________________________________________
Signature of officer
Title
Phone number
Date
___________________________________________________________________________________________________________________________________________
Signature of preparer
Address of preparer
Phone number
Date
Do Not Detach Coupon
DR-142
Solid Mineral Severance Tax Return
R. 01/13
Handwritten Example
Typed Example
0 1 2 3 4 5 6 7 8 9
0123456789
Return is due 1st day of the 4th month after close of the taxable year
Use black ink.
Year
M
M
D
D Y
Y
US DOLLARS
CENTS
,
,
Ending
Total amount due
from Line 21
Check here if you transmitted funds electronically.
Enter name and address, if not preprinted:
,
,
Total credit
from Line 22
,
,
Name
Total refund
from Line 23
Address
City/St/ZIP
FEIN
Enter FEIN if not preprinted
DR-142
Do Not Write in the Space Below.
9100 0 99999999 0013042031 6 3999999999 0000 2

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