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SD EForm - 0896
South Dakota Department Of Revenue
Energy Minerals Severance Tax And Conservation Tax
Report for the quarter ending
Name of Designated Operator:
Company Name (if different from above):
ame of Preparer
consumed on site)
Average posted field price, sale price, or market value per unit
3. Gross value (line 1 x line 2)
4a Royalties Deductions:
5. Total deductions (total lines 4a & 4b)
6. Taxable value (line 3 less line 5)
7. Severance tax due (line 6 x 4.5%)
8. Conservation tax due (line 6 x 0.0024)
9. TOTAL TAX DUE (total all columns on line 7 and line 8) . . . . . . . . . . . . . . . . . . ___________________________________________
Allocation to each county based on taxable value of the energy minerals produced in each county.
SEVERANCE TAX DUE
(from line 7)
Under penalties of perjury, I declare that the foregoing is a full and true statement of the amount and value of the minerals
extracted during the period indicated and to the best of my knowledge it is true, correct and complete.
Signature __________________________________________________ Date ________________________________________
Name of Company_________________________________________________________________________________________
Prepare in duplicate: submit one copy within 30 days following the close of each quarter to the Department of Revenue, Special
Tax Division, 445 E Capitol Ave., Pierre, SD 57501-3100. Retain one copy in company files for audit purposes.
Complete the schedule on the reverse side or attach a separate schedule showing such information.