Free Tc-96 Royalty.cdr - Utah

See Royalty Production Coupon Below

Clear form
Cut Here and Submit The Lower Portion

Utah Mineral Production Withholding Return, TC-96
Account No. Tax Tax Period Due Date

ROYALTY
1. Amount withheld this period 2. Amount remitted with this return

RW

R
Under penalties provided by law, I declare, to the best of my knowledge, that this return is true and correct.

X Signature

Date

Phone no.

File a return even if there is no tax liability. Make check or money order payable to the Utah State Tax Commission. Do not send cash. Do not staple check to this coupon. Detach check stub.

UTAH STATE TAX COMMISSION 210 N 1950 W SLC UT 84134-0100