instructions for 4121: annual gross products breakdown by tax district ...
INSTRUCTIONS FOR 4121: ANNUAL GROSS PRODUCTS BREAKDOWN BY TAX DISTRICT FOR OIL INSTRUCTIONS FOR 4221: ANNUAL GROSS PRODUCTS BREAKDOWN BY TAX DISTRICT FOR GAS
COMPLETE 4121 (oil) or 4221 (gas) FOR EACH PROPERTY WHERE YOU HAVE 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 more districts in two or more counties. PRODUCTION YEAR: calendar year in which production occurred. TAXPAYER INFORMATION SECTION: Operator ID - Taxpayer's Operator ID as assigned by the Wyoming Oil and Gas Conservation Commission (WOGCC), or as assigned by the Mineral Tax Division of the Wyoming Department of Revenue. Taxpayer - Taxpayer's name. NOT agent. PRODUCING ASSET SECTION: Reporting Group Number - the Reporting assigned by the Mineral Tax Division.
Group
number
Reporting Group Name - Name of the producing asset. TAX DISTRICT BREAKDOWN OF TAXABLE VALUE Tax District - Enter county prefix and tax district. The county prefix and tax district of each well will be supplied to the operator by the Mineral Tax Division. EXAMPLE: Campbell County District 0100 would be 050100. Volume Produced - Operators enter volume produced and attributable to this tax district (well head volume). TIK interest owners skip this column. Volume Sold - Operators enter sales volume attributable to this tax district. TIK Interest owners enter volume taken in-kind attributable to this tax district.
Instructions for 4121 and 5221
Page 2
Taxable Value - Enter the dollar amount of 4101 Section D Line 9, attributable to the tax district listed. Totals - The total of the Volume Produced Column, (operators only), must equal 4101 Section D Line 4 (Oil), or 4201 Section C Line 1 (gas); the total of the Volume Sold Column must equal 4101 Section D Line 6 (oil), or 4201 Section D Line 6 plus Line 7 (gas); the total of the taxable value column must equal 4101 or 4201 Section D Line 9.
COUNTY PREFIXES Albany Big Horn Campbell Carbon Converse Crook Fremont Goshen Hot Springs Johnson Laramie Lincoln
01 03 05 07 09 11 13 15 17 19 21 23
Natrona Niobrara Park Platte Sheridan Sublette Sweetwater Teton Uinta Washakie Weston
25 27 29 31 33 35 37 39 19 43 45
rev. 12/5/2000
Gross Products Tax Reporting Instructions State of Wyoming Department of Revenue 122 West 25th Street Cheyenne, WY 82002-0110
TAXPAYER INFORMATION Operator ID
!"#$%!&
ANNUAL GROSS PRODUCTS FOR GAS
4201
Production Year:
__ __ __ __
Revenue Use Only
PRODUCING ASSET Taxpayer
Reporting Group Number
Contact Person / Agent
Telephone Number
Address
Reporting Group Name Field Name
City
State
A. Form Type:
O = Original A = Amended
Explanation for Amendment:
Zip
County
O = Operator B. Taxpayer Type: T = Take Calendar Year in in-Kind Interest Owner Contact Person or which Production Agent's telephone occurred. number including area
codebyand extension. C. Gross MCF Calculation (Complete Operator ONLY) 1)
Total Well-Head Production
Taxpayer’s Operator ID 2a Flared/Blown MCF 2b Re-injection MCF 2)
as assigned the Wyoming Oil and Gas 2c Field Useby MCF 2d Other MCF Conservation Commission (WOGCC), or as assigned by the Mineral Tax Division. Total Well-Head Deductions (Line 2a + 2b + 2c + 2d)
3)
Gross Production at Mouth (Line 1 minus Line 2)
Taxpayer’s name. not- COMPLETE enter an agent’s nameONLY here. TIK Interest Owner VolumeDo Taken BY OPERATOR TIK Interst Owner Name TIK Operator ID Volume Taken
4a)
Name of the person, agent, or agency responsible for completing this report who can answer 4b) questions regarding this report. 4c) TIK Interest Owner Volume Taken from 4211 MTD
4d) Taxpayer's, or agent's, mailing address. Total Take In-Kind Volume - (Line 4a + 4b + 4c + 4d) 4)
D. Taxable Value Calculation Gross Sales Volume of Natural Gas (Line 3 minus Line 4) 5) Gross Sales Value of Natural Gas (No Plant Products) 6) Gross Sales Value of Plant Products (Complete Form 4231) 7) 8a Federal Royalty $
8b State Royalty $
8c Tribal Royalty $
8d Processing $
Type A Transportation USE 4201 TO REPORT GAS, AND LIQUIDS SEPARATED AT A PROCESSING Type B Transportation PLANT.Type ALWAYS REPORT ALL VOLUMES AND VALUES ROUNDED TO THE C Transportation NEAREST NUMBER. 8e) WHOLE Total Transportation Deductions
8) 9)
Total Deductions (8a + 8b + 8c + 8d + 8e) Taxable Value - (Line 6 plus Line 7 minus Line 8) 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 12/16/99
Form 4201 Page 1
Gross Products Tax Reporting Instructions
!"#$%!&
State of Wyoming Department of Revenue 122 West 25th Street Cheyenne, WY 82002-0110
Operator ID
ANNUAL GROSS PRODUCTS FOR GAS The Reporting Group Number assigned by Production Year: the TAXPAYER Mineral TaxINFORMATION Division
4201
__ __ __ __
Revenue Use Only
PRODUCING ASSET
Name of the Field where the property is Taxpayer located as designated by the Wyoming Oil and Gas Conservation Commission Contact Person / Agent Telephone Number (WOGCC) Address City
Reporting Group Number
Reporting Group Name Field Name
Wyoming County where the property is State located
Zip
County
Reporting Group Name A. Form Type:
O = Original A = Amended
B. Taxpayer Type:
O = Operator T = Take in-Kind Interest Owner
Explanation for Amendment: C. Gross MCF Calculation (Complete by Operator ONLY) 1)
Total Well-Head Production
2a Flared/Blown MCF
2b Re-injection MCF
2c Field Use MCF
2d Other MCF
2) Total Well-Head Deductions (Line 2a + 2b +Enter 2c + 2d) ‘O’ if you are the operator of Enter 3) ‘O’ for an original this 2) property. Enter ‘T’ if you are Gross Production at Mouth (Line 1 minus Line report. TIK Enter ‘A’Owner for an anONLY interest owner taking Interest Volume Taken - COMPLETE BY OPERATOR TIK Interst Owner Name TIK Operator ID Volume Taken amended report production in-kind on this 4a) property 4b) 4c) 4d)
4)
For amended reports, list the specific reason(s) for the amendment.
TIK Interest Owner Volume Taken from 4211 MTD
Total Take In-Kind Volume - (Line 4a + 4b + 4c + 4d)
D. Taxable Value Calculation Gross Sales Volume of Natural Gas (Line 3 minus Line 4) 5) Gross Sales Value of Natural Gas (No Plant Products) 6) Gross Sales Value of Plant Products (Complete Form 4231) 7) 8a Federal Royalty $
8b State Royalty $
8c Tribal Royalty $
8d Processing $
Type A Transportation Type B Transportation Type C Transportation 8e) Total Transportation Deductions Total Deductions (8a + 8b + 8c + 8d + 8e) 8) Taxable Value - (Line 6 plus 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 12/16/99
Form 4201 Page 2
Gross Products Tax Reporting Instructions
!"#$%!&
State of Wyoming Department of Revenue 122 West 25th Street Cheyenne, WY 82002-0110
ANNUAL GROSS PRODUCTS GROSS MCF CALCULATION. (Take FOR in-kindGAS interest owners skip to 4201 Section D.) TAXPAYER INFORMATION Production Year: __ __ __ __ Operator ID Revenue Use Only Total well-head production. Enter total production recorded at the well head PRODUCING ASSET prior to any adjustments or deductions.
Taxpayer
Reporting Group Number
Contact Person Enter/ Agent volume
Group that has been lawfullyTelephone flaredNumber or vented Reporting pursuant toName authorization to vent or flare by the Wyoming Oil and Gas Conservation Address Field Name Commission (WOGCC). City
State
Zip
County
Enter volume that has been re-injected for re-pressuring or pressure maintenance into the same field and formation from which it was removed. This volume is O = Original O = Operator A. Form Type: excluded the gross product until B. it isTaxpayer otherwiseType: used or consumed, orInterest Owner A =from Amended T = Take sold in-Kind exchanged. Explanation for Amendment: C. Gross MCF Calculation (Complete by Operator ONLY) 1)
Total Well-Head Production
2a Flared/Blown MCF
2b Re-injection MCF
2c Field Use MCF
2)
Total Well-Head Deductions (Line 2a + 2b + 2c + 2d)
3)
Gross Production at Mouth (Line 1 minus Line 2)
2d Other MCF
TIK Interest Owner Volume Taken - COMPLETE BY OPERATOR ONLY TIK Interst Owner Name TIK Operator ID Volume Taken
Enter volume 4a) consumed to produce crude oil and natural gas on the same lease or unit from which it was produced. 4b) 4c)
Enter only prior approval TIK deduction Interest Owner that Volumehas Takenreceived from 4211 MTD 4d) a well An explanation must be attached to from the MineralTotal TaxTake Division. In-Kind Volume - (Line 4a + 4b + 4c + 4d) 4) 2d is completed. 4201 if Box D. Taxable Value Calculation Gross Sales Volume of Natural Gas (Line 3 minus Line 4) 5) (2aProducts) + 2b + 2c + 2d). Gross Enter Sales total Valuewell-head of Naturaldeductions Gas (No Plant 6) Gross Sales Value of Plant Products (Complete Form 4231) 7) 8a Federal Royalty $
8b State Royalty $
8c Tribal Royalty $
8d Processing $
Enter the gross production at the mouth of well (Line 1 minus Line 2).
Type A Transportation Type B Transportation Type C Transportation 8e) Total Transportation Deductions Total Deductions (8a + 8b + 8c + 8d + 8e) 8)
9)
Taxable Value - (Line 6 plus Line 7 minus Line 8) 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
MTS2
Date
Form 4201 Page 3
Gross Products Tax Reporting Instructions State of Wyoming Department of Revenue 122 West 25th Street Cheyenne, WY 82002-0110
TAXPAYER INFORMATION Operator ID
!"#$%!&
ANNUAL GROSS PRODUCTS FOR GAS
4201
Production Year:
__ __ __ __
Revenue Use Only
PRODUCING ASSET Taxpayer
Reporting Group Number
Contact Person / Agent
Telephone Number
Reporting Group Name
Field NameIN-KIND ONLY: itemize OPERATOR WHO IS DEDUCTING PRODUCTION TAKEN each interest owner taking production in-kind who is reporting on their own behalf and the City State Zip County 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 O = Original O = Operator A. Form Type: B. Taxpayer Type: A = Amended T = Take in-Kind Interest Owner and attach 4211. Address
Explanation for Amendment: Operator Only: enter total volume taken in-kind from C. Gross MCF Calculation 4211 if any. (Complete by Operator ONLY) 1)
Total Well-Head Production
2a Flared/Blown MCF
2b Re-injection MCF
2c Field Use MCF
2)
Total Well-Head Deductions (Line 2a + 2b + 2c + 2d)
3)
Gross Production at Mouth (Line 1 minus Line 2)
2d Other MCF
TIK Interest Owner Volume Taken - COMPLETE BY OPERATOR ONLY TIK Interst Owner Name TIK Operator ID Volume Taken
4a) 4b) 4c) 4d)
4)
TIK Interest Owner Volume Taken from 4211 MTD Total Take In-Kind Volume - (Line 4a + 4b + 4c + 4d)
D. Taxable Value Calculation Gross Sales Volume of Natural Gas (Line 3 minus Line 4) 5) Gross Sales Value of Natural Gas (No Plant Products) 6) Gross Sales Value of Plant Products (Complete FormOnly: 4231) enter the total volume taken in7) Operator 8a Federal Royalty $ 8b State Royalty $ 8c Tribalkind, Royalty(4a+4b+4c+4d). $ 8d Processing $ Type A Transportation Type B Transportation Type C Transportation 8e) Total Transportation Deductions Total Deductions (8a + 8b + 8c + 8d + 8e) 8)
9)
Taxable Value - (Line 6 plus Line 7 minus Line 8) 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
MTS2
Date
Form 4201 Page 4
Gross Products Tax Reporting Instructions State of Wyoming Department of Revenue 122 West 25th Street Cheyenne, WY 82002-0110
TAXPAYER INFORMATION Operator ID
!"#$%!&
ANNUAL GROSS PRODUCTS FOR GAS
4201
Production Year:Line__4 __ __ Enter mcf sold (Line 3 minus for__ operators; volume taken in-kind for take in-kind interest owners). PRODUCING ASSET
Revenue Use Only
Taxpayer
Reporting Group Number
(skip to line 7 if you have plant products) Enter the gross sales value for Number Group Name the year whereTelephone no plant products Reporting are involved. Gross Sales Value includes all revenue relating to the production for the reported year, Field Name including tax reimbursements and all other revenue received or credited to all interest owners not taking in-kind State Zip County and reporting on their own behalf, and including all Federal, State, or Tribal royalty owner's interest.
Contact Person / Agent Address City
O = Original O = Operator A. Form Type: B. Taxpayer Type: A = Amended T = Take in-Kind Interest Owner Enter the gross sales value for the year where plant products are involved. Gross Sales includes all revenue relating to the production for the reported year, Explanation for Value Amendment: 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. Gross MCF Calculation (Complete by Operator ONLY) including all Federal, State, or Tribal royalty owner's interest. Complete and 1) Total Well-Head Production include Form 4231 when plant products are involved. 2a Flared/Blown MCF 2b Re-injection MCF 2c Field Use MCF 2d Other MCF
Well-Head Deductions (Line 2a + 2b + 2c + 2d) Enter the2)value Total of the Federal Royalty Exemption, if any. Gross Production Mouth of (Line 1 minus Line 2) NOTE: if3)the exemption exceedsat12.5% Line 7, attach an TIK Interest Owner Volume Taken - COMPLETE BY OPERATOR ONLY explanation. TIK Interst Owner Name
TIK Operator ID
Volume Taken
4a)
Enter the State Royalty Exemption, if any.
4b) 4c) 4d)
TIK Interest Owner Volume Taken from 4211 MTD Enter the Tribal
4)
Total Take In-Kind Volume - (Line 4a + 4b + 4c + 4d)
Royalty Exemption, if any.
D. Taxable Value Calculation Gross Sales Volume of Natural Gas (Line 3 minus Line 4) 5) Gross Sales Value of Natural Gas (No Plant Products) 6) Gross Sales Value of Plant Products (Complete Form 4231) 7) 8a Federal Royalty $
8b State Royalty $
8c Tribal Royalty $
8d Processing $
Type A Transportation Type B Transportation Type C Transportation Enter allowable plant processing costs. Line 7 must contain a value 8e) Total Transportation Deductions and Form 4231 be +completed and included to report a Total Deductions (8a + 8b +must 8c + 8d 8e) 8)
9)
processing deduction. Taxable Value - (Line 6 plus Line 7 minus Line 8)
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
MTS2
Date
Form 4201 Page 5
Gross Products Tax Reporting Instructions State of Wyoming Department of Revenue 122 West 25th Street Cheyenne, WY 82002-0110
TAXPAYER INFORMATION Operator ID
!"#$%!&
ANNUAL GROSS PRODUCTS FOR GAS
4201
Production Year:
__ __ __ __
Revenue Use Only
PRODUCING ASSET Taxpayer
Reporting Group Number
Contact Person / Agent
Telephone Number
Address
Reporting Group Name Field Name
State is the actual Zip cost of transportation County Allowable Type A Transportation from the outlet of the initial dehydrator to the inlet of the main transmission line or main processing plant. O = Original O = Operator A. Form Type: B. Taxpayer Type: A = Amended T = Take in-Kind Interest Owner
City
Explanation When for no Amendment: dehydration is performed, other than within a processing facility, allowable Type B Transportation is the actual cost of transportation from the inlet to the related compressor, custody ONLY) transfer meter, or processing facility, C. Grosstransportation MCF Calculation (Complete by Operator whichever occurs first, to the inlet of the main processing plant or main transmission line. 1) Total Well-Head Production If no dehydration the field andUsethere transportation related 2a Flared/Blown MCF is performed 2b Re-injectionin MCF 2c Field MCF is no 2d Other MCF compressor or custody transfer meter there is no Type B Transportation deduction. 2)
Total Well-Head Deductions (Line 2a + 2b + 2c + 2d)
3)Allowable GrossType Production at Mouth (Line 1 minus Line 2) of transportation from the inlet of the C Transportation is the actual cost TIK Interest Owner Volume Taken COMPLETE BY main OPERATOR ONLY plant to main transmission line or -outlet of the processing TIK Interst Owner Name TIK Operator ID Volume Taken
market, where transportation
is included in the price.
4a) 4b) 4c) 4d)
4)
Enter the total transportation deduction (Type A + Type B + Type C). NOTE: TYPE A TRANSPORTATION PLUS TYPE B TRANSPORTATION CANNOT EXCEED 50 TIK Interest Owner Volume Taken from 4211 MTD PERCENT OF THE GROSS SALES VALUE (LINE 6 AND/OR LINE 7) WITHOUT Total Take In-Kind Volume - (Line 4a + 4b + 4c + 4d) APPROVAL OF THE DEPARTMENT (WS 39-14-203(b)(xi)).
D. Taxable Value Calculation Deductions (8a + 8b + 8c + 8d + 8e). Gross Sales Volume of Natural Gas (Line 3Enter minusTotal Line 4) 5) Gross Sales Value of Natural Gas (No Plant Products) 6) Enter Taxable Value (Line 6 plus Line 7 minus Line 8). Gross Sales Value of Plant Products (Complete Form 4231) 7) 8a Federal Royalty $
8b State Royalty $
8c Tribal Royalty $
8d Processing $
Type A Transportation Type B Transportation Type C Transportation 8e) Total Transportation Deductions Total Deductions (8a + 8b + 8c + 8d + 8e) 8)
9)
Taxable Value - (Line 6 plus Line 7 minus Line 8) 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
MTS2
Date
Form 4201 Page 6
Gross Products Tax Reporting Instructions State of Wyoming Department of Revenue 122 West 25th Street Cheyenne, WY 82002-0110
TAXPAYER INFORMATION Operator ID
!"#$%!&
ANNUAL GROSS PRODUCTS FOR GAS
4201
Production Year:
__ __ __ __
Revenue Use Only
PRODUCING ASSET Taxpayer
Reporting Group Number
Contact Person / Agent
Telephone Number
Address
Reporting Group Name Field Name
City
State
A. Form Type:
Zip
O = Original A = Amended
County
B. Taxpayer Type:
O = Operator T = Take in-Kind Interest Owner
Explanation for Amendment: C. Gross MCF Calculation (Complete by Operator ONLY) 1)
Total Well-Head Production
2a Flared/Blown MCF
2b Re-injection MCF
2c Field Use MCF
2)
Total Well-Head Deductions (Line 2a + 2b + 2c + 2d)
3)
Gross Production at Mouth (Line 1 minus Line 2)
2d Other MCF
TIKForm Interest4201 Owner for Volume - COMPLETE BY OPERATOR ONLYby February theTaken 2001 Production Year is due TIK Interst Owner Name TIK Operator ID Volume Taken
25, 2002.
4a) Mail completed forms to: 4b) Wyoming Department of Revenue 4c) Mineral Tax Division 4d)
122 West 25thOwner Street TIK Interest Volume Taken from 4211 MTD Cheyenne WY 82002-0110
Total Take In-Kind Volume - (Line 4a + 4b + 4c + 4d) 4) D. Taxable Value Calculation All paper forms must be signed and dated originals, faxed returns will not be accepted. Gross Sales Volume of Natural Gas (Line 3 minus Line 4) 5) Gross Sales Value of Natural Gas (No Plant Products) 6) Gross Sales Value of Plant Products (Complete Form 4231) 7) 8a Federal Royalty $
8b State Royalty $
8c Tribal Royalty $
8d Processing $
Type A Transportation Type B Transportation Type C Transportation 8e) Total Transportation Deductions Total Deductions (8a + 8b + 8c + 8d + 8e) 8) Taxable Value - (Line 6 plus 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.
Authorized Signature
Title
MTS2 12/16/99
Date Form 4201 Page 7
!"##$!
COMPLETE 4121 (oil) or 4221 (gas) FOR EACH PROPERTY WHERE YOU HAVE 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 more districts in two or more counties. PRODUCTION YEAR: calendar year in which production occurred. TAXPAYER INFORMATION SECTION: Operator ID - Taxpayer's Operator ID as assigned by the Wyoming Oil and Gas Conservation Commission (WOGCC), or as assigned by the Mineral Tax Division of the Wyoming Department of Revenue. Taxpayer - Taxpayer's name. NOT agent. PRODUCING ASSET SECTION: Reporting Group Number - the Reporting assigned by the Mineral Tax Division.
Group
number
Reporting Group Name - Name of the producing asset. TAX DISTRICT BREAKDOWN OF TAXABLE VALUE Tax District - Enter county prefix and tax district. The county prefix and tax district of each well will be supplied to the operator by the Mineral Tax Division. EXAMPLE: Campbell County District 0100 would be 050100. Volume Produced - Operators enter volume produced and attributable to this tax district (well head volume). TIK interest owners skip this column. Volume Sold - Operators enter sales volume attributable to this tax district. TIK Interest owners enter volume taken in-kind attributable to this tax district.
Instructions for 4121 and 5221
Page 2
Taxable Value - Enter the dollar amount of 4101 Section D Line 9, attributable to the tax district listed. Totals - The total of the Volume Produced Column, (operators only), must equal 4101 Section D Line 4 (Oil), or 4201 Section C Line 1 (gas); the total of the Volume Sold Column must equal 4101 Section D Line 6 (oil), or 4201 Section D Line 6 plus Line 7 (gas); the total of the taxable value column must equal 4101 or 4201 Section D Line 9.
COUNTY PREFIXES Albany Big Horn Campbell Carbon Converse Crook Fremont Goshen Hot Springs Johnson Laramie Lincoln
01 03 05 07 09 11 13 15 17 19 21 23
Natrona Niobrara Park Platte Sheridan Sublette Sweetwater Teton Uinta Washakie Weston
25 27 29 31 33 35 37 39 19 43 45
rev. 12/5/2000
Gross Products Tax Reporting Instructions State of Wyoming Department of Revenue 122 West 25th Street Cheyenne, WY 82002-0110
TAXPAYER INFORMATION Operator ID
!"#$%!&
ANNUAL GROSS PRODUCTS FOR GAS
4201
Production Year:
__ __ __ __
Revenue Use Only
PRODUCING ASSET Taxpayer
Reporting Group Number
Contact Person / Agent
Telephone Number
Address
Reporting Group Name Field Name
City
State
A. Form Type:
O = Original A = Amended
Explanation for Amendment:
Zip
County
O = Operator B. Taxpayer Type: T = Take Calendar Year in in-Kind Interest Owner Contact Person or which Production Agent's telephone occurred. number including area
codebyand extension. C. Gross MCF Calculation (Complete Operator ONLY) 1)
Total Well-Head Production
Taxpayer’s Operator ID 2a Flared/Blown MCF 2b Re-injection MCF 2)
as assigned the Wyoming Oil and Gas 2c Field Useby MCF 2d Other MCF Conservation Commission (WOGCC), or as assigned by the Mineral Tax Division. Total Well-Head Deductions (Line 2a + 2b + 2c + 2d)
3)
Gross Production at Mouth (Line 1 minus Line 2)
Taxpayer’s name. not- COMPLETE enter an agent’s nameONLY here. TIK Interest Owner VolumeDo Taken BY OPERATOR TIK Interst Owner Name TIK Operator ID Volume Taken
4a)
Name of the person, agent, or agency responsible for completing this report who can answer 4b) questions regarding this report. 4c) TIK Interest Owner Volume Taken from 4211 MTD
4d) Taxpayer's, or agent's, mailing address. Total Take In-Kind Volume - (Line 4a + 4b + 4c + 4d) 4)
D. Taxable Value Calculation Gross Sales Volume of Natural Gas (Line 3 minus Line 4) 5) Gross Sales Value of Natural Gas (No Plant Products) 6) Gross Sales Value of Plant Products (Complete Form 4231) 7) 8a Federal Royalty $
8b State Royalty $
8c Tribal Royalty $
8d Processing $
Type A Transportation USE 4201 TO REPORT GAS, AND LIQUIDS SEPARATED AT A PROCESSING Type B Transportation PLANT.Type ALWAYS REPORT ALL VOLUMES AND VALUES ROUNDED TO THE C Transportation NEAREST NUMBER. 8e) WHOLE Total Transportation Deductions
8) 9)
Total Deductions (8a + 8b + 8c + 8d + 8e) Taxable Value - (Line 6 plus Line 7 minus Line 8) 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 12/16/99
Form 4201 Page 1
Gross Products Tax Reporting Instructions
!"#$%!&
State of Wyoming Department of Revenue 122 West 25th Street Cheyenne, WY 82002-0110
Operator ID
ANNUAL GROSS PRODUCTS FOR GAS The Reporting Group Number assigned by Production Year: the TAXPAYER Mineral TaxINFORMATION Division
4201
__ __ __ __
Revenue Use Only
PRODUCING ASSET
Name of the Field where the property is Taxpayer located as designated by the Wyoming Oil and Gas Conservation Commission Contact Person / Agent Telephone Number (WOGCC) Address City
Reporting Group Number
Reporting Group Name Field Name
Wyoming County where the property is State located
Zip
County
Reporting Group Name A. Form Type:
O = Original A = Amended
B. Taxpayer Type:
O = Operator T = Take in-Kind Interest Owner
Explanation for Amendment: C. Gross MCF Calculation (Complete by Operator ONLY) 1)
Total Well-Head Production
2a Flared/Blown MCF
2b Re-injection MCF
2c Field Use MCF
2d Other MCF
2) Total Well-Head Deductions (Line 2a + 2b +Enter 2c + 2d) ‘O’ if you are the operator of Enter 3) ‘O’ for an original this 2) property. Enter ‘T’ if you are Gross Production at Mouth (Line 1 minus Line report. TIK Enter ‘A’Owner for an anONLY interest owner taking Interest Volume Taken - COMPLETE BY OPERATOR TIK Interst Owner Name TIK Operator ID Volume Taken amended report production in-kind on this 4a) property 4b) 4c) 4d)
4)
For amended reports, list the specific reason(s) for the amendment.
TIK Interest Owner Volume Taken from 4211 MTD
Total Take In-Kind Volume - (Line 4a + 4b + 4c + 4d)
D. Taxable Value Calculation Gross Sales Volume of Natural Gas (Line 3 minus Line 4) 5) Gross Sales Value of Natural Gas (No Plant Products) 6) Gross Sales Value of Plant Products (Complete Form 4231) 7) 8a Federal Royalty $
8b State Royalty $
8c Tribal Royalty $
8d Processing $
Type A Transportation Type B Transportation Type C Transportation 8e) Total Transportation Deductions Total Deductions (8a + 8b + 8c + 8d + 8e) 8) Taxable Value - (Line 6 plus 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 12/16/99
Form 4201 Page 2
Gross Products Tax Reporting Instructions
!"#$%!&
State of Wyoming Department of Revenue 122 West 25th Street Cheyenne, WY 82002-0110
ANNUAL GROSS PRODUCTS GROSS MCF CALCULATION. (Take FOR in-kindGAS interest owners skip to 4201 Section D.) TAXPAYER INFORMATION Production Year: __ __ __ __ Operator ID Revenue Use Only Total well-head production. Enter total production recorded at the well head PRODUCING ASSET prior to any adjustments or deductions.
Taxpayer
Reporting Group Number
Contact Person Enter/ Agent volume
Group that has been lawfullyTelephone flaredNumber or vented Reporting pursuant toName authorization to vent or flare by the Wyoming Oil and Gas Conservation Address Field Name Commission (WOGCC). City
State
Zip
County
Enter volume that has been re-injected for re-pressuring or pressure maintenance into the same field and formation from which it was removed. This volume is O = Original O = Operator A. Form Type: excluded the gross product until B. it isTaxpayer otherwiseType: used or consumed, orInterest Owner A =from Amended T = Take sold in-Kind exchanged. Explanation for Amendment: C. Gross MCF Calculation (Complete by Operator ONLY) 1)
Total Well-Head Production
2a Flared/Blown MCF
2b Re-injection MCF
2c Field Use MCF
2)
Total Well-Head Deductions (Line 2a + 2b + 2c + 2d)
3)
Gross Production at Mouth (Line 1 minus Line 2)
2d Other MCF
TIK Interest Owner Volume Taken - COMPLETE BY OPERATOR ONLY TIK Interst Owner Name TIK Operator ID Volume Taken
Enter volume 4a) consumed to produce crude oil and natural gas on the same lease or unit from which it was produced. 4b) 4c)
Enter only prior approval TIK deduction Interest Owner that Volumehas Takenreceived from 4211 MTD 4d) a well An explanation must be attached to from the MineralTotal TaxTake Division. In-Kind Volume - (Line 4a + 4b + 4c + 4d) 4) 2d is completed. 4201 if Box D. Taxable Value Calculation Gross Sales Volume of Natural Gas (Line 3 minus Line 4) 5) (2aProducts) + 2b + 2c + 2d). Gross Enter Sales total Valuewell-head of Naturaldeductions Gas (No Plant 6) Gross Sales Value of Plant Products (Complete Form 4231) 7) 8a Federal Royalty $
8b State Royalty $
8c Tribal Royalty $
8d Processing $
Enter the gross production at the mouth of well (Line 1 minus Line 2).
Type A Transportation Type B Transportation Type C Transportation 8e) Total Transportation Deductions Total Deductions (8a + 8b + 8c + 8d + 8e) 8)
9)
Taxable Value - (Line 6 plus Line 7 minus Line 8) 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
MTS2
Date
Form 4201 Page 3
Gross Products Tax Reporting Instructions State of Wyoming Department of Revenue 122 West 25th Street Cheyenne, WY 82002-0110
TAXPAYER INFORMATION Operator ID
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ANNUAL GROSS PRODUCTS FOR GAS
4201
Production Year:
__ __ __ __
Revenue Use Only
PRODUCING ASSET Taxpayer
Reporting Group Number
Contact Person / Agent
Telephone Number
Reporting Group Name
Field NameIN-KIND ONLY: itemize OPERATOR WHO IS DEDUCTING PRODUCTION TAKEN each interest owner taking production in-kind who is reporting on their own behalf and the City State Zip County 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 O = Original O = Operator A. Form Type: B. Taxpayer Type: A = Amended T = Take in-Kind Interest Owner and attach 4211. Address
Explanation for Amendment: Operator Only: enter total volume taken in-kind from C. Gross MCF Calculation 4211 if any. (Complete by Operator ONLY) 1)
Total Well-Head Production
2a Flared/Blown MCF
2b Re-injection MCF
2c Field Use MCF
2)
Total Well-Head Deductions (Line 2a + 2b + 2c + 2d)
3)
Gross Production at Mouth (Line 1 minus Line 2)
2d Other MCF
TIK Interest Owner Volume Taken - COMPLETE BY OPERATOR ONLY TIK Interst Owner Name TIK Operator ID Volume Taken
4a) 4b) 4c) 4d)
4)
TIK Interest Owner Volume Taken from 4211 MTD Total Take In-Kind Volume - (Line 4a + 4b + 4c + 4d)
D. Taxable Value Calculation Gross Sales Volume of Natural Gas (Line 3 minus Line 4) 5) Gross Sales Value of Natural Gas (No Plant Products) 6) Gross Sales Value of Plant Products (Complete FormOnly: 4231) enter the total volume taken in7) Operator 8a Federal Royalty $ 8b State Royalty $ 8c Tribalkind, Royalty(4a+4b+4c+4d). $ 8d Processing $ Type A Transportation Type B Transportation Type C Transportation 8e) Total Transportation Deductions Total Deductions (8a + 8b + 8c + 8d + 8e) 8)
9)
Taxable Value - (Line 6 plus Line 7 minus Line 8) 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
MTS2
Date
Form 4201 Page 4
Gross Products Tax Reporting Instructions State of Wyoming Department of Revenue 122 West 25th Street Cheyenne, WY 82002-0110
TAXPAYER INFORMATION Operator ID
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ANNUAL GROSS PRODUCTS FOR GAS
4201
Production Year:Line__4 __ __ Enter mcf sold (Line 3 minus for__ operators; volume taken in-kind for take in-kind interest owners). PRODUCING ASSET
Revenue Use Only
Taxpayer
Reporting Group Number
(skip to line 7 if you have plant products) Enter the gross sales value for Number Group Name the year whereTelephone no plant products Reporting are involved. Gross Sales Value includes all revenue relating to the production for the reported year, Field Name including tax reimbursements and all other revenue received or credited to all interest owners not taking in-kind State Zip County and reporting on their own behalf, and including all Federal, State, or Tribal royalty owner's interest.
Contact Person / Agent Address City
O = Original O = Operator A. Form Type: B. Taxpayer Type: A = Amended T = Take in-Kind Interest Owner Enter the gross sales value for the year where plant products are involved. Gross Sales includes all revenue relating to the production for the reported year, Explanation for Value Amendment: 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. Gross MCF Calculation (Complete by Operator ONLY) including all Federal, State, or Tribal royalty owner's interest. Complete and 1) Total Well-Head Production include Form 4231 when plant products are involved. 2a Flared/Blown MCF 2b Re-injection MCF 2c Field Use MCF 2d Other MCF
Well-Head Deductions (Line 2a + 2b + 2c + 2d) Enter the2)value Total of the Federal Royalty Exemption, if any. Gross Production Mouth of (Line 1 minus Line 2) NOTE: if3)the exemption exceedsat12.5% Line 7, attach an TIK Interest Owner Volume Taken - COMPLETE BY OPERATOR ONLY explanation. TIK Interst Owner Name
TIK Operator ID
Volume Taken
4a)
Enter the State Royalty Exemption, if any.
4b) 4c) 4d)
TIK Interest Owner Volume Taken from 4211 MTD Enter the Tribal
4)
Total Take In-Kind Volume - (Line 4a + 4b + 4c + 4d)
Royalty Exemption, if any.
D. Taxable Value Calculation Gross Sales Volume of Natural Gas (Line 3 minus Line 4) 5) Gross Sales Value of Natural Gas (No Plant Products) 6) Gross Sales Value of Plant Products (Complete Form 4231) 7) 8a Federal Royalty $
8b State Royalty $
8c Tribal Royalty $
8d Processing $
Type A Transportation Type B Transportation Type C Transportation Enter allowable plant processing costs. Line 7 must contain a value 8e) Total Transportation Deductions and Form 4231 be +completed and included to report a Total Deductions (8a + 8b +must 8c + 8d 8e) 8)
9)
processing deduction. Taxable Value - (Line 6 plus Line 7 minus Line 8)
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
MTS2
Date
Form 4201 Page 5
Gross Products Tax Reporting Instructions State of Wyoming Department of Revenue 122 West 25th Street Cheyenne, WY 82002-0110
TAXPAYER INFORMATION Operator ID
!"#$%!&
ANNUAL GROSS PRODUCTS FOR GAS
4201
Production Year:
__ __ __ __
Revenue Use Only
PRODUCING ASSET Taxpayer
Reporting Group Number
Contact Person / Agent
Telephone Number
Address
Reporting Group Name Field Name
State is the actual Zip cost of transportation County Allowable Type A Transportation from the outlet of the initial dehydrator to the inlet of the main transmission line or main processing plant. O = Original O = Operator A. Form Type: B. Taxpayer Type: A = Amended T = Take in-Kind Interest Owner
City
Explanation When for no Amendment: dehydration is performed, other than within a processing facility, allowable Type B Transportation is the actual cost of transportation from the inlet to the related compressor, custody ONLY) transfer meter, or processing facility, C. Grosstransportation MCF Calculation (Complete by Operator whichever occurs first, to the inlet of the main processing plant or main transmission line. 1) Total Well-Head Production If no dehydration the field andUsethere transportation related 2a Flared/Blown MCF is performed 2b Re-injectionin MCF 2c Field MCF is no 2d Other MCF compressor or custody transfer meter there is no Type B Transportation deduction. 2)
Total Well-Head Deductions (Line 2a + 2b + 2c + 2d)
3)Allowable GrossType Production at Mouth (Line 1 minus Line 2) of transportation from the inlet of the C Transportation is the actual cost TIK Interest Owner Volume Taken COMPLETE BY main OPERATOR ONLY plant to main transmission line or -outlet of the processing TIK Interst Owner Name TIK Operator ID Volume Taken
market, where transportation
is included in the price.
4a) 4b) 4c) 4d)
4)
Enter the total transportation deduction (Type A + Type B + Type C). NOTE: TYPE A TRANSPORTATION PLUS TYPE B TRANSPORTATION CANNOT EXCEED 50 TIK Interest Owner Volume Taken from 4211 MTD PERCENT OF THE GROSS SALES VALUE (LINE 6 AND/OR LINE 7) WITHOUT Total Take In-Kind Volume - (Line 4a + 4b + 4c + 4d) APPROVAL OF THE DEPARTMENT (WS 39-14-203(b)(xi)).
D. Taxable Value Calculation Deductions (8a + 8b + 8c + 8d + 8e). Gross Sales Volume of Natural Gas (Line 3Enter minusTotal Line 4) 5) Gross Sales Value of Natural Gas (No Plant Products) 6) Enter Taxable Value (Line 6 plus Line 7 minus Line 8). Gross Sales Value of Plant Products (Complete Form 4231) 7) 8a Federal Royalty $
8b State Royalty $
8c Tribal Royalty $
8d Processing $
Type A Transportation Type B Transportation Type C Transportation 8e) Total Transportation Deductions Total Deductions (8a + 8b + 8c + 8d + 8e) 8)
9)
Taxable Value - (Line 6 plus Line 7 minus Line 8) 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
MTS2
Date
Form 4201 Page 6
Gross Products Tax Reporting Instructions State of Wyoming Department of Revenue 122 West 25th Street Cheyenne, WY 82002-0110
TAXPAYER INFORMATION Operator ID
!"#$%!&
ANNUAL GROSS PRODUCTS FOR GAS
4201
Production Year:
__ __ __ __
Revenue Use Only
PRODUCING ASSET Taxpayer
Reporting Group Number
Contact Person / Agent
Telephone Number
Address
Reporting Group Name Field Name
City
State
A. Form Type:
Zip
O = Original A = Amended
County
B. Taxpayer Type:
O = Operator T = Take in-Kind Interest Owner
Explanation for Amendment: C. Gross MCF Calculation (Complete by Operator ONLY) 1)
Total Well-Head Production
2a Flared/Blown MCF
2b Re-injection MCF
2c Field Use MCF
2)
Total Well-Head Deductions (Line 2a + 2b + 2c + 2d)
3)
Gross Production at Mouth (Line 1 minus Line 2)
2d Other MCF
TIKForm Interest4201 Owner for Volume - COMPLETE BY OPERATOR ONLYby February theTaken 2001 Production Year is due TIK Interst Owner Name TIK Operator ID Volume Taken
25, 2002.
4a) Mail completed forms to: 4b) Wyoming Department of Revenue 4c) Mineral Tax Division 4d)
122 West 25thOwner Street TIK Interest Volume Taken from 4211 MTD Cheyenne WY 82002-0110
Total Take In-Kind Volume - (Line 4a + 4b + 4c + 4d) 4) D. Taxable Value Calculation All paper forms must be signed and dated originals, faxed returns will not be accepted. Gross Sales Volume of Natural Gas (Line 3 minus Line 4) 5) Gross Sales Value of Natural Gas (No Plant Products) 6) Gross Sales Value of Plant Products (Complete Form 4231) 7) 8a Federal Royalty $
8b State Royalty $
8c Tribal Royalty $
8d Processing $
Type A Transportation Type B Transportation Type C Transportation 8e) Total Transportation Deductions Total Deductions (8a + 8b + 8c + 8d + 8e) 8) Taxable Value - (Line 6 plus 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.
Authorized Signature
Title
MTS2 12/16/99
Date Form 4201 Page 7
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