Form 5010 - Severance Tax Report Undrground Coal Page 3
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3State of Wyoming
5010
SEVERANCE TAX REPORT
Department of Revenue
122 West 25th Street
5010
UNDRGROUND COAL
Cheyenne WY 82002-0110
DOR USE ONLY:
Operator ID:
Taxpayer Name:
O - Original
Prod Period:
A - Amended
REPORTING
RATE
TONS SOLD
SALES VALUE
TONS MINED
TAXABLE VALUE
TOTAL TAX DUE
PREVIOUS
TAX DUE
NUMBER
CODE
TAX PAID
(AMENDS)
REV. 5/19/99
PAGE TOTAL:
REPORT TOTAL:
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.
Authorized Signature
Title
Date
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