Form 4101 - Annual Gross Products For Oil Page 5
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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
Calendar Year in which
Contact Person or Agent's
Production occurred.
O = Original
O = Operator
A. Form Type:
B. Taxpayer Type:
telephone number including
A = Amended
T = Take in-Kind Interest Owner
area code and extension.
Explanation for Amendment:
Taxpayer’s Operator ID as assigned by the Wyoming Oil and Gas Conservation
Commission (WOGCC), or as assigned by the Mineral Tax Division.
Claim for Stripper Rate
C.
1)
Number of producing oil wells and active injection wells on this property
Taxpayer’s name. Do not enter an agent’s name here.
2)
Number of well days curtailed by mechanical failure or disruption
3)
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.)
Name of the person, agent, or agency responsible for completing this report who can answer questions regarding
this report.
D. Total Production and Sales for the period:
Volume Produced - COMPLETE BY OPERATOR ONLY (Total gross production for the period)
4)
Taxpayer's, or agent's, mailing address.
TIK Interest Owner Volume Taken - COMPLETE BY OPERATOR ONLY
TIK Interest Owner Name
TIK Operator ID
Volume Taken
5a)
5b)
5c)
5d)
TIK Interest Owner Volume Taken from 4111 MTD
Total Take In-Kind Volume - (Line 5a + 5b + 5c + 5d)
5)
Volume Sold - (Taxpayer’s volume sold)
6)
USE 4101 TO REPORT OIL, AND LIQUIDS SEPARATED AT THE LEASE (Lease
Sales Value - (Gross sales value for the period)
7)
8a Federal Royalty $
8b State Royalty $
8c Tribal Royalty $
8d Transportation $
Condensate). ALWAYS REPORT ALL VOLUMES AND VALUES ROUNDED TO THE
NEAREST WHOLE NUMBER.
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
Form 4101 page 1
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