Form 4101 - Annual Gross Products For Oil Page 10
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11Gross Products Tax Reporting Instructions
State of Wyoming
ANNUAL GROSS PRODUCTS FOR OIL
Department of Revenue
122 West 25th Street
4101
Cheyenne, WY 82002-0110
Production Year:
TAXPAYER INFORMATION
__ __ __ __
Operator ID
Revenue Use Only
PRODUCING ASSET
Taxpayer
Reporting Group Number
Contact Person / Agent
Telephone Number
Reporting Group Name
Address
Field Name
City
State
Zip
County
O = Original
O = Operator
A. Form Type:
B. Taxpayer Type:
A = Amended
T = Take in-Kind Interest Owner
Explanation for Amendment:
C.
Claim for Stripper Rate
1)
Number of producing oil wells and active injection wells on this property
Form 4101 for the 2001 Production Year is due by February 25, 2002.
2)
Number of well days curtailed by mechanical failure or disruption
Mail completed forms to:
3)
Number of well days produced at maximum feasible rate times 10 bbls
Wyoming Department of Revenue
( Times 15 bbls after 1994 if price is less than $20.00 bbl.)
Mineral Tax Division
D. Total Production and Sales for the period:
th
122 West 25
Street
4)
Volume Produced - COMPLETE BY OPERATOR ONLY (Total gross production for the period)
Cheyenne WY 82002-0110
TIK Interest Owner Volume Taken - COMPLETE BY OPERATOR ONLY
TIK Interest Owner Name
TIK Operator ID
Volume Taken
All paper forms must be signed and dated originals, faxed returns will not be accepted.
5a)
5b)
5c)
TIK Interest Owner Volume Taken from 4111 MTD
5d)
Total Take In-Kind Volume - (Line 5a + 5b + 5c + 5d)
5)
Volume Sold - (Taxpayer’s volume sold)
6)
Sales Value - (Gross sales value for the period)
7)
8a Federal Royalty $
8b State Royalty $
8c Tribal Royalty $
8d Transportation $
Total Deductions - (Line 8a + 8b + 8c + 8d)
8)
Taxable Value - (Line 7 minus line 8)
9)
I declare under penalty of perjury that I have examined this return, and , to the best of my knowledge and belief, it is correct and complete.
MTS2
Authorized Signature
Title
Date
Form 4101 page 6
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