nm3clol-public/Russell_County/Commissioner_of_Revenue/Application%20to%20Sever%20Coal%2C%20Gas%20or%20Oil/README.md

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document	Application%20to%20Sever%20Coal%2C%20Gas%20or%20Oil	../Application%20to%20Sever%20Coal%2C%20Gas%20or%20Oil.pdf	Russell_County Commissioner_of_Revenue	null	application/pdf	160421	2cdb74486be8d4304ef75b1412e5b9babeba17df9a7bbde4a9ff7204ad6d9120	0d8f57e44c20fce6257c92eec322fd6b7cddf8e6

VIRGINIA UNIFORM LICENSE APPLICATION TO SEVER COAL, GAS, OR OIL FROM LANDS SITUATED IN RUSSELL COUNTY, VIRGINIA

MAILTO: COMMISSIONER OF THE REVENUE. Po Box 517 LEBANON, VA 24266

DUE MARCH 1, 20

OPERATOR’S NAME: ‘TELEPHONE NUMBER: ADDRESS:

CITY: STATE: ZIP:

SOAL

MINE NAME & NUMBER:

MINE INDEX NUMBER: DMLR#: MSHA#:

MINE TYPE: (cHscKoNs) UNDERGROUND OSURFACE OAUGER — O OTHER (Arzcu ExpLANArion) DATE OPERATION BEGAN AT THIS LOCATION: PREVIOUS MINE INDEX #:

GAS/

WELL TYPE: (CHECK ONE) Gas Qo QLIQUID GAS

DMME OPERATIONS NAME: DMME APPLICATION #: ‘TYPE OF OPERATIO! DMME FILE NUMBER:

WELL COMPLETION DATE: : DEPTH OF WELL:

OATH: _ I, THE UNDERSIGNED OPERATOR OR AUTHORIZED AGENT, DO SWEAR (OR AFFIRM) THAT I AM AUTHORIZED TO. FILE THIS APPLICATION.

‘Signature of Operator or Authorized Agent ‘Operator or Agent's Name (Print) Title SWORN (OR AFFIRMED) ON THIS DAY OF 520, . TELEPHONE #: EMAIL ADDRESS: + FAXNUMBER:

1, THE COMMISSIONER OF THE REVENUE, DO FIND THE FOREGOING APPLICATION FOR LICENSE OR RENEWAL OF LICENSE IN DUE FORM. THEREFORE, SUCH LICENSE(S) ARE THIS DAY GRANTED OR RENEWED TO THE OPERATOR NAMED IN THE ‘APPLICATION FOR LICENSE TO PROSECUTE THE BUSINESS OF SEVERING COAL, GASES, OR OIL FROM LANDS SITUATED IN COUNTY, VIRGINIA, AS PROVIDED ON SAID APPLICATION, ACCORDING TO THE TERMS AND CONDITIONS OF THE ENABLING ORDINANCE AND BY PROPER COMPUTATION OF THE TAXES THEREON, AND THE PAYMENT THEREOF AS REQUIRED

WITHIN 20 DAYS OF THE CLOSE OF EACH CALENDAR MONTH.

‘COMMISSIONER OF THE REVENUE DATE

OPERATOR SHALL COMPLETE THE FOLLOWING: (Attach additional sheets if necessary)

OWNER’S INFORMATIO!

CHECK TYPE

OWNER'S NAME OWNER'S ADDRESS

% OF OWNERSHIP. |" DEED | LEASE

1.) What type of entity isthe operator? Sole Proprietorship:

• Pull Names and addresses ofeach officer and director ofthe corporation:

President:

‘Treasurer: Director: Director:

Seoretary: Director: Director:

• Ifthe corporation is a subsidiary corporation: ‘Name and Address of the parent corporation:

' Vice President: |

State of incorporation of parent corporation:

Partnership: “State of registration:

= Type of partnership: General Limited Lipa

** Full names, addresses and type (general or limited) of each partner, director, corporate officer, or member:

Foreign Q

Oo Le: » State of registration:

• Full names and addresses ofall members:

2.) Is there an agreement between the operator and any other contractor or business entity to sever coal, gas, or oil? YesQ) No

• Ifyes, name and address of business:

" Does the agreement allow the contractor or business entity to sell the severed coal, gas, or oil through Yes) No an outside market?

• Is the contractor or business entity related to the operator through common ownership? Yes Noo Ifyes, how?

3.) An operator is considered to have utilized coal, gs, or oil severed in County ifsuct coal, gas, oro is put to.use for such purposes as facility heating or operating machinery and equipment, oF for any other purpose other than safe,

• Does the operator utilize any coal, gas, or oil severed in County? Yes Noo
• If yes, isthe fair market value of this coal, gas, or oil included inthe computation of gross receipts, as. Yes) NoO reported on this application?
• If yes, please indicate the approximate percentage of the coal, ga, or oil used in your operations:

In the calculation of fair market value for the purpose of reporting gross receipts, does the operator deduct costs? Yes No

• Ifyes, please itemize any and all deductions taken within the county, including but not limited to, depreciation, marketing fees, overhead, compression, line loss, maintenance, transportation fes, utilization for operations royalty payments, and personal

property:

‘otal amount ofall deduction: $.

5.) Does the owner sell for utilization any coal, gas, or oil to partes loceted within County? Yes NoO

• If yes, isthe far market value of this coal, gas, or oil included in the computation of gross receipts? Yes). No

• Ifo, to whom is the coal, gas, or oil sold? 6.) Does the owner place any coal, gas, or oil in transit for shipment from County? YesQ NoO

• Ifyes, at what point is the coal, gas, or oil placed in transit? Yes No

• Is the coal, gas, or ofl a marketable product when placed in transit?

7.) Does the owner maintain sufficient written and contemporaneous records to verily the accuracy of the information contained within this application and all attachments? Yes No. ‘+ What types of records are maintained?

"Where are these records maintained?

Name and ttle of person(s) responsible for the maintenance of these records:

8. If this application is for a gas or oil operation, does this operator sever any gas in connection with coal mining? Yes). No

is operator and the coat