Alternative Tax Credit For Oil And Gas Exploration Under As 43.55.025 Page 4
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7Alaska
310
Alternative Tax Credit for Oil and Gas
Exploration under AS 43.55.025
Schedule C - Data Release Form
Federal EIN
Date of Claim
Name of Single Explorer or Designated Joint Applicant
Name and Location of Seismic, Geophysical, or Exploration Well Project
Completion Date of Exploration Activity
Lessor Information
Federal EIN of Lessor
Name of Lessor
Mailing Address
City
State
Zip Code
Contact Name
Contact Title
Contact Phone
Contact Email Address
In accordance with the requirements under AS 43.55.025, we, the undersigned, understand that all the required data for the
geophysical, seismic, or exploration well project referred to above will be provided to the State of Alaska. We acknowledge,
understand, and agree that the data provided may be publicly disclosed as part of the requirements under AS 43.55.025.
Signature of Single Explorer or Designated Joint Applicant
Date
Printed Name
Title
Telephone Number
Signature of Lessor
Date
Printed Name
Title
Telephone Number
This form is available online at
Submit completed applications via the Tax Division Online Tax Information
System (OTIS) at
310
0405-310 Rev 09/06/13- page 4
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