Form 4101 - Annual Gross Products For Oil Page 8
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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
Address
Field Name
City
State
Zip
County
Operator; enter the total gross production volume for the year.
Take In-Kind Interest Owner; skip to line 6
O = Original
O = Operator
A. Form Type:
B. Taxpayer Type:
A = Amended
T = Take in-Kind Interest Owner
Explanation for Amendment:
OPERATOR WHO IS DEDUCTING PRODUCTION TAKEN IN-KIND ONLY: itemize each interest owner taking production in-
kind who is reporting on their own behalf and the volume taken. Accurately enter the TIK interest owner’s name and Operator ID. If
the Operator ID is unknown, contact the Mineral Tax Division. If there are more than three interest owners taking production in-kind
who are reporting on their own behalf, complete and attach 4111
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
Operator Only: enter total volume taken in-kind from 4111 if any.
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)
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)
Operator Only: enter the total volume taken in-kind, (5a+5b+5c+5d).
8a Federal Royalty $
8b State Royalty $
8c Tribal Royalty $
8d Transportation $
Total Deductions - (Line 8a + 8b + 8c + 8d)
8)
Enter barrels sold
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 4
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