REPORT PERIOD ENDING DUE DATE: TAXPAYER UTAH ACCOUNT NUMBER
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TC-5 REV. 4/04
Operator/ Amend Producing Prod. Entity No. Type Other + -
QUARTERLY OIL' AND GAS CONSERVATION FEE RETURN
Volume Transported Reported by Others Subject to Fee Product Value Processing/ Transportation Deduction (attach detail schedule)
Round all volumes and values to whole numbers.
Royalties Indian State Federal Value Subject To Fee
Adjusted Product Value
I have reviewed this report and certify the information to be accurate and complete. Authorized Signature Date Preparer Name Telephone
TOTAL (value subject to fee) FEE DUE (value X .002) GRAND TOTAL (fee due all pages)
UTAH ACCOUNT NUMBER REPORT PERIOD
Enter Utah account number of the company submitting this report. Number is assigned by Utah Division of Oil, Gas and Mining. Report period covers one calendar quarter. The due dates for these reports are: 1st QTR: Jan 1 - Mar 31 due on or before June 1 2nd QTR: Apr 1 - Jun 30 due on or before September 1 3rd QTR: Jul 1 - Sep 30 due on or before December 1 4th QTR: Oct 1 - Dec 31 due on or before March 1 of next year Enter name of company submitting this report. Check appropriate boxes to indicate whether reporting as Operator or Other. Check box if this report is changing or updating information previously submitted. Amended(+-): This column is to be used only when an amended report is filed. Amended reports include only specific product and producing entity being corrected. Report should contain the following: Original Entry-Use a minus(-) on first line to indicate original entry being deleted. Entry should be written as it appeared on original return. Corrected Entry-Use a plus(+) on second line to indicate corrected entry. Producing Entity Number: Enter number assigned to producing entity by Utah Division of Oil, Gas and Mining. Product Type: Enter one of the following codes for product type: OL-Oil; GS-Gas; NL-Natural Gas Liquids. Transported: Enter quantity of product produced, saved, sold or transported from producing entity. Reported by Other: Enter volume of product takenin-kind by another party. If entry is made in this column, Form TC-806 should be submitted.
transported minus reported by others. Product Value: Product value is value of volume subject to fee before any deductions. Processing/Transportation Deduction: Enter the amount of processing and transportation costs, as defined by Utah Code 59-5-101, allowable as a deduction from product value. A schedule with a detailed breakdown of these costs taken as a deduction, must be provided. deduction from product value. State Royalties: Deduct the amount of royalties equal to the percentage of exempt royalty interest attributable to the state or political subdivision of the state from the producing entity. Indian Royalties: Deduct the amount of royalties equal to the percentage of exempt royalty interest attributable to an Indian or Indian Tribe for lands subject to the supervision of the United States from producing entity. Federal Royalties: Deduct the amount of royalties equal to the percentage of exempt royalty interest attributable to the United States from the producing entity. Value Subject To Fee: Value amount equals adjusted product value minus State, Indian and Federal royalties. TOTAL Value Subject To Fee: Total of values shown in the "Value Subject To Fee" column. FEE DUE: Multiply total value amount by .002. GRAND TOTAL: Enter grand total of fee due on last page of return only. Preparer should sign report and enter the date and telephone number at bottom. Mail report and any remittance to: Utah State Tax Commission 210 North 1950 West Salt Lake City, UT 84134 For additional information, contact the Utah State Tax Commission, telephone (801) 297-2200 or go to our website at tax.utah.gov. FORM TXOGF4 4/04
Volume Subject To Fee: Volume subject to fee equals volume
Adjusted Product Value: Subtract processing/transportation