Free 684B - Utah

Schedule B Oil and Gas Severance Tax Annual Return
Operator First Purchaser Interest Owner

Utah State Tax Commission

Clear form

TC-684B Rev. 6/03

Utah State Tax Commission - 210 North 1950 West - Salt Lake City, Utah 84134 - Telephone (801) 297-2200

Get forms online tax.utah.gov

Other (Explain) _________________________________________

DESIGNATION OF WORKOVER OR RECOMPLETION
1. Taxpayer's Name 3. Taxpayer's Address 4. Report Period (Year) 2. Utah Account Number

N-

5. Well Name and Number 6. API Well Number 7. Field Name 8. Field Code Number

9. Date work commenced ___________

Date work completed ___________

Date work approved by Division of Oil, Gas and Mining ___________

10. LIST WORKING INTEREST OWNERS WHO TAKE PRODUCT IN KIND AND ARE AUTHORIZED TO SHARE IN THE TAX CREDIT.
Name Address Utah Account No. Percent of Interest

11. 12. 13. 14. 15. 16.

List the total approved expenses for Workover or Recompletion (Under rule R649-3-23 Division of Oil, Gas and Mining) ....................................................................................................................................................................................... Workover or Recompletion Credit (Line 11 x 20%) cannot exceed $30,000 per well each calendar year Allowable current year credit (Line 12 multiplied by interest owned) .............................................................................. Carryover nonrefundable tax credit from prior three years (if none, enter 0) ............................................................ Total nonrefundable tax credit available (line 13 plus line 14) Carry line 15 to line 14 of the Oil and Gas Severance Tax Annual Return. This cannot exceed the total tax liability. If line 15 is larger than the tax liability, enter the excess on line 16. Unused credit to be carried over to the next year. _____________ AMOUNT

684B.frm

SEVERANCE TAX ANNUAL RETURN SCHEDULE B INSTRUCTIONS
INSTRUCTIONS FOR BOXES LINE 10.

Check the appropriate box to indicate whether reporting as Operator, Interest Owner, First Purchaser, or Other. Check the amended box if this report is changing or updating information previously submitted. Enter name of company submitting this report. Enter the Utah Account Number of the company submitting this report. The number is assigned by the Utah Division of Oil, Gas and Mining. Enter the address of the company submitting this report. Report period covers the calendar year from 12:01 am of the first day to 12:00 pm of the last day. Enter the name and number of the well assigned by the Utah Division of Oil, Gas and Mining. Enter the API number of the well assigned by the Utah Division of Oil, Gas and Mining. Enter the field name in which the well is located. (Assigned by the Utah Division of Oil, Gas and Mining) Enter numerical field code in which the well is located. (Assigned by the Utah Division of Oil, Gas and Mining) Enter the dates operations were commenced, completed and approved.

LINE 1. TAXPAYER'S NAME

List only working interest owners who take product in kind. Provide the working interest owner's names, addresses, and Utah account numbers specified for the working interest owners by the Utah Division of Oil, Gas and Mining. Show the percent of ownership to the seventh decimal place. List the total expenses incurred for the workover or recompletion as approved by the Utah Division of Oil, Gas and Mining on Form 15. Expenses must have been approved before tax credit can be taken. Multiply line 11 by 20%. Utah law allows a nonrefundable tax credit equal to 20% of the approved recompletion or workover expenses not to exceed $30,000 per well during each calendar year. Multiply line 12 by the interest owned in the well. (May be all or part of the expense of workover or recompletion.) Carryover of unused credit from previous three years filed on Schedule B. Total nonrefundable tax credit available to be used on line 14 of the Annual Severance Tax Return, TC-684. This credit cannot exceed total tax liability. If line 15 is larger than total tax liability, the unused credit may be carried to the next year. Enter unused credit to claim against next year's tax liability.

LINE 2. UTAH ACCOUNT NUMBER

LINE 11.

LINE 3. TAXPAYER'S ADDRESS LINE 4. REPORT PERIOD

LINE 12.

LINE 5. WELL NAME AND NUMBER LINE 6. API WELL NUMBER LINE 7. FIELD NAME LINE 8. FIELD CODE LINE 9.

LINE 13. LINE 14. LINE 15.

LINE 16.

684bi Rev. 6/03