Form 4101 - Annual Gross Products For Oil Page 11
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11ANNUAL GROSS PRODUCTS FOR OIL
State of Wyoming
Department of Revenue
122 West 25th Street
4101
Cheyenne, WY 82002-0110
TAXPAYER INFORMATION
__ __ __ __
Production Year:
Operator ID
Revenue Use Only
PRODUCING ASSET
Taxpayer
Reporting Group Number
Contact Person / Agent
Telephone Number
Reporting Group Name
Address
Field Name
State
Zip
County
City
O = Original
O = Operator
Form Type:
Taxpayer Type:
A.
B.
A = Amended
T = Take in-Kind Interest Owner
Explanation for Amendment:
+
.
Claim for Stripper Rate
1)
Number of producing oil wells and active injection wells on this property
Number of well days curtailed by mechanical failure or disruption
Number of well days produced at maximum feasible rate times 10 bbls
!
( Times 15 bbls after 1994 if price is less than $20.00 bbl.)
D.
Total Production and Sales for the period:
"
Volume Produced - COMPLETE BY OPERATOR ONLY (Total gross production for the period)
TIK Interest Owner Volume Taken - COMPLETE BY OPERATOR ONLY
TIK Interest Owner Name
TIK Operator ID
Volume Taken
#=
#>
#?
TIK Interest Owner Volume Taken from 4111 MTD
#@
Total Take In-Kind Volume - (Line 5a + 5b + 5c + 5d)
#
Volume Sold - (Taxpayer’s volume sold)
$
Sales Value - (Gross sales value for the period)
%
8a Federal Royalty $
8b State Royalty $
8c Tribal Royalty $
8d Transportation $
Total Deductions - (Line 8a + 8b + 8c + 8d)
&
Taxable Value - (Line 7 minus line 8)
'
MTS2
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.
12/16/99
Authorized Signature
Title
Date
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