Form 4101 - Annual Gross Products For Oil Page 6
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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
The Reporting Group Number assigned by the Mineral
TAXPAYER INFORMATION
Production Year:
__ __ __ __
Tax Division
Operator ID
Revenue Use Only
PRODUCING ASSET
Name of the Field where the property is located as
Taxpayer
Reporting Group Number
designated by the Wyoming Oil and Gas
Conservation Commission (WOGCC)
Contact Person / Agent
Telephone Number
Reporting Group Name
Address
Field Name
Wyoming County where the property is located
City
State
Zip
County
Reporting Group Name
O = Original
O = Operator
A. Form Type:
B. Taxpayer Type:
A = Amended
T = Take in-Kind Interest Owner
Explanation for Amendment:
Claim for Stripper Rate
C.
Enter ‘O’ if you are the operator of this
1)
Number of producing oil wells and active injection wells on this property
Enter ‘O’ for an original report.
property. Enter ‘T’ if you are an interest
Enter ‘A’ for an amended report
owner taking production in-kind on this
2)
Number of well days curtailed by mechanical failure or disruption
property
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.)
D. Total Production and Sales for the period:
For amended reports, list the specific reason(s) for the
Volume Produced - COMPLETE BY OPERATOR ONLY (Total gross production for the period)
4)
amendment.
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)
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
Form 4101 page 2
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