Form 4121 - Annual Gross Products Breakdown By County/tax District For Oil Page 3
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5Gross Products Tax Reporting Instructions
State of Wyoming
ANNUAL GROSS PRODUCTS
Department of Revenue
BREAKDOWN BY COUNTY/TAX
122 West 25th Street
4121
Cheyenne, WY 82002-0110
DISTRICT FOR OIL
Production Year:
__ __ __ __
TAXPAYER INFORMATION
PRODUCING ASSET
Operator ID
Revenue Use Only
Reporting Group Number
Calendar year in which production occurred.
Taxpayer
Reporting Group Name
B. Tax District Breakdown of Taxable Value
County & Tax District
Volume Produced
Volume Sold
Taxable Value
Taxpayer’s Operator ID as assigned by the Wyoming Oil and Gas
Reporting Group Name
Conservation Commission (WOGCC), or as assigned by the
Mineral Tax Division.
The Reporting Group
Number assigned by the
Taxpayer’s name. Do not enter an agent’s name here.
Mineral Tax Division
Enter the County Prefix and Tax District.
Operators enter sales volume
The County Prefix and Tax District of
attributable to this Tax District.
each well will be supplied to the Operator
Take In-Kind Interest Owners enter
by the Mineral Tax Division. Example:
volume taken attributable to this
Campbell County District 100 would be
Tax District.
entered as 050100.
Enter the dollar amount of Form 4101
Operators enter the volume produced and
Section D Line 9 attributable to this
attributable to this Tax District. Take In-Kind
Tax District.
Interest Owners skip this column.
TOTALS
Note: Total Volume Produced must equal 4101, Section D, Line 4; Total Volume Sold must equal 4101, Section D, Line 6; Total Taxable Value must
equal 4101, Section D, Line 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
COMPLETE FORM 4121 FOR EACH PROPERTY WHERE YOU HAVE
1/19/00
REGISTERED A REPORTING GROUP THAT CONTAINS WELLS IN
MULTIPLE TAX DISTRICTS. MULTIPLE TAX DISTRICTS CAN BE
TWO OR MORE DISTRICTS IN THE SAME COUNTY OR TWO OR
Authorized Signature
Title
Date
MORE DISTRICTS IN TWO OR MORE COUNTIES.
Form 4121 page 1
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