Form 4101 - Annual Gross Products For Oil Page 9
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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
O = Original
O = Operator
A. Form Type:
B. Taxpayer Type:
A = Amended
T = Take in-Kind Interest Owner
Explanation for Amendment:
Enter the gross sales value for the year. Gross Sales Value includes all revenue relating to the production for the reported year, including tax
reimbursements and all other revenue received or credited to all interest owners not taking in-kind and reporting on their own behalf, and
C.
Claim for Stripper Rate
including all Federal, State, or Tribal royalty owner's interest.
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
Enter the value of the Federal Royalty Exemption, if any. NOTE: if the exemption exceeds 12.5% of
( Times 15 bbls after 1994 if price is less than $20.00 bbl.)
Line 7, attach an explanation.
D. Total Production and Sales for the period:
Enter the State Royalty Exemption, if any.
4)
Volume Produced - COMPLETE BY OPERATOR ONLY (Total gross production for the period)
TIK Interest Owner Volume Taken - COMPLETE BY OPERATOR ONLY
Enter the Tribal Royalty Exemption, if any.
TIK Interest Owner Name
TIK Operator ID
Volume Taken
5a)
5b)
Enter Transportation “to market” costs which occur between the well head and point of sale for
which you can produce invoices for verification
5c)
TIK Interest Owner Volume Taken from 4111 MTD
5d)
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
Enter 8a+8b+8c+8d
12/16/99
Enter Line 7 minus Line 8.
Authorized Signature
Title
Date
Form 4101 page 5
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