Form 4101 - Annual Gross Products For Oil Page 7
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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
TAXPAYER INFORMATION
Production Year:
__ __ __ __
Operator ID
Revenue Use Only
PRODUCING ASSET
Taxpayer
Reporting Group Number
Contact Person / Agent
Telephone Number
Reporting Group Name
Operator; mark an ‘X’ in the box and complete lines one, two, and three.
Address
Field Name
Take in-kind interest owner; do not complete Section C. Stripper qualification is based
upon the operator’s report.
City
State
Zip
County
O = Original
O = Operator
A. Form Type:
B. Taxpayer Type:
A = Amended
T = Take in-Kind Interest Owner
If a single well is registered for the Reporting Group enter 1. If multiple wells are registered to the Reporting Group enter
the total number of registered producing oil wells and active injection wells in the Reporting Group. Gas wells are not
Explanation for Amendment:
counted.
Claim for Stripper Rate
C.
1)
Number of producing oil wells and active injection wells on this property
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.)
D. Total Production and Sales for the period:
Volume Produced - COMPLETE BY OPERATOR ONLY (Total gross production for the period)
4)
If a single well is registered for the Reporting Group enter the number of days that you wanted to produce but
TIK Interest Owner Volume Taken - COMPLETE BY OPERATOR ONLY
could not due to mechanical failure or disruption. If multiple wells are registered to the Reporting Group enter
TIK Interest Owner Name
TIK Operator ID
Volume Taken
the total number of days for each well that you wanted to produce but could not due to mechanical failure or
5a)
disruption.
5b)
5c)
5d)
TIK Interest Owner Volume Taken from 4111 MTD
Multiply Line 1 times 365 days then subtract Line 2. Multiply this remainder times 10. [If Sales Value (line D7) divided by
Total Take In-Kind Volume - (Line 5a + 5b + 5c + 5d)
5)
Volume Sold (line D6) is less than $20, multiply this remainder times 15.] If Line 3 is equal to, or greater than, Section D, Line 4,
Volume Sold - (Taxpayer’s volume sold)
6)
the property qualifies for the stripper rate.
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 3
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