QUARTERLY
F
29
IDAHO OIL AND GAS
O
R
EFO00245
PRODUCTION TAX STATEMENT
M
06-11-12
TAX ON OIL AND GAS PRODUCED IN IDAHO
FOR THE QUARTER ENDING ___________________, _________
(Month)
(Year)
Name of producer
Social Security Number or EIN
Business mailing address
City, state and ZIP Code
COMPUTATION OF TAX DUE
If the producer has production in more than one county, use the schedule on page 2 to report for each county
and enter the totals for all counties on lines 1-4 below.
County where production took place
_____________________________________________________________
1. Total volume of oil produced (from page 2, Section III, line 5, if more than one county.) ............
2. Total volume of gas produced (from page 2, Section III, line 6, if more than one county.) ..........
3. Total sales of oil and gas produced (from page 2, Section III, line 7, if more than
one county.) (Don't include oil or gas reported on line 4.) ...........................................................
4. Total value of oil and gas transported from premises before sale (from page 2,
Section III, line 8, if more than one county.) ...............................................................................
5. Subtotal. (Add lines 3 and 4.) .....................................................................................................
6. Tax due. (Multiply line 5 by the tax rate.) ....................................................................................
7. Adjustments. (Attach explanation of why the adjustment was necessary.) ................................
8. Total tax due ................................................................................................................................
9. Interest from due date .................................................................................................................
10. Penalty ........................................................................................................................................
11. Total due ......................................................................................................................................
SIGNATURE AND VERIFICATION
Under penalties of perjury, I declare that to the best of my knowledge and belief this return is true, correct, and complete.
Signature of officer/owner
Date
Paid preparer's signature
Preparer's EIN, SSN, or PTIN
SIGN
HERE
Title
Phone number
Preparer's address and phone number
This statement is to be filed with the Idaho State Tax Commission on or before the 20th of the month following the end of
the reporting quarter. Payment of the total due must be enclosed.
MAIL TO: Idaho State Tax Commission, PO Box 36, Boise, ID 83722-0410