Form Mt-10 - Purchaser-Operator Registration Form
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1OFFICE USE ONLY
Purchaser
(check only one)
Purchase I.D. Number ____________________
Operator
(check only one)
KANSAS DEPARTMENT OF REVENUE
CUSTOMER RELATIONS
MINERAL TAX
TOPEKA, KANSAS 66625-0918
PHONE: 785-296-7713
Fax: 785-296-4993
PURCHASER-OPERATOR REGISTRATION FORM
Business Name
Mailing Address
City
State
Zip Code
Business Address if different from above
Telephone No.
FEIN
Fax No.
Email Address
❏
❏
Type of Ownership:
Individual
Corporation
❏
❏
Partnership
Other
Date of Purchase
❏
❏
Type of Purchase:
Crude Oil
Natural Gas
Name and address of individual owner, partners, or corporate officers:
Name
Address
Title
List of operators from whom you purchase:
Name
Operator ID No.
(Attach additional sheet if necessary)
CERTIFICATE: The above statements are hereby certified to be correct to the best knowledge of the undersigned.
Signed:
Title:
Date:
(Signature of Owner or Partner or Officer if corporation)
MT-10
(Rev. 3/10)
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Parent category: Financial