nm3clol-public/Russell_County/Commissioner_of_Revenue/Monthly Form to Sever Coal, Gases, or Oil

type	title	file	tags	docDate	contentType	contentLength	sha256sum	sha1sum
document	Monthly Form to Sever Coal, Gases, or Oil	../Monthly Form to Sever Coal, Gases, or Oil.pdf	Russell_County Commissioner_of_Revenue	null	application/pdf	92174	240a9590f6b5843f673075cea1c8ab34f96d824ab93d6aed508ba31be6a2b276	6e45795bf55cfe32a9108e88e09565ed1ffb68ed

MAIL RETURN & PAYMENT TO: COMMISSIONER OF THE REVENUE PO BOX 517 LEBANON, VA 242656

MAKE CHECKS PAYABLE TO: ‘TREASURER OF RUSSELL COUNTY

MONTHLY RETURN

TO SEVER COAL GASES, OR OIL FROM LANDS ‘SITUATED IN RUSSELL COUNTY, VIRGINIA

For the calendar month of , Year,

OPERATOR'S NAME: TELEPHONE#: | ADDRESS: cry: STATE: ZIP: COAL: MINE NAME & NUMBER: MINE INDEX #: MINE TYPE: DATE OPERATION BEGAN AT THIS LOCATION: DMLR #: MSHA #: PREVIOUS MINE INDEX NUMBER: GAS / OIL: WELL TYPE (CHECK ONE): Q GAs Q OIL Q LIQUID GAS OPERATIONSNAME: DMME APPLICATION TYPE OF OPERATION; _ DMME FILE NUMBER: WELL COMPLETION DATE: DEPTH OF WELL: UE ON OR TH mIeTH (20

IT IS REQUIRED THAT YOU FILE A RETURN WITH OUR OFFICE EACH MONTH. DAY OF EACH MONTH IMMEDIATI TH WERE SEVERED. A RETURN THAT IS NOT FILED

TIMELY SHALL INCUR A PENALTY OF 10%, PLUS INTEREST AT THE RATE OF 5% PER ANNUM. FAILURE TO FILE THE MONTHLY RETURN AND TO PAY THE APPLICABLE TAXES BY THE TWENTIETH (20) DAY OF THE MONTH IMMEDIATELY FOLLOWING THE MONTH IN WHICH ‘THE MINERALS WERE SEVERED MAY RESULT IN A SUSPENSION OF YOUR LICENSE,

‘GROSS TONS |= GROSS] SNES] Tgenge | SEVERED FOR | Recelprs ron | pice rer | sasis PENALTY | rerest | BALANCE DUE “THE MONTH | iE MONTH: nae 2 zi COAL SEVERANCE 2% GROSS MCF °F GROSS A]: SALE > TEESE | seteneoFon | recerteron | eniceren | ease | tax | PMA’ | meres | pacance ous THE MONTN. | “imeMONTN’| © Mice : as ‘SEVERANCE 3% cen EPP ca eros |" sate : report. | eames | pect petites [aan | tax | PematTY | wreneor | pauanos ous _THE MONTH ‘THE MONTH."=|° BARREL®.| 2 OL a sevetince 05% TOTAL PAYMENT:

OATH: 1, THE UNDERSIGNED AGENT, DO SWEAR (OR AFFIRM) UNDER PENALTY OF PERJURY, THAT THE FOREGOING FIGURES AND STATEMENTS ARE TRUE, CORRECT, AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND BELIEF, AND THAT TAM

AUTHORIZED TO FILE THIS RETURN.

‘Signature of Operator or Authorized Agent Operator or Agent's Name (Prini) Title SWORN (OR AFFIRMED) ON THIS DAY OF 20, ‘TELEPHONE NUMBER: EMAIL ADDRESS: . FAX NUMBER:

"THIS RETURN SHALL NOT BE VALID OR HAVE ANY LEGAL EFFECT UNLESS AND UNTIL THE TAXES PRESCRIBED BY LAW (AND ANY APPLICABLE PENALTIES AND INTEREST). AS SHOWN ON THE FOREGOING RETURN, ARE PAID TO THE TREASURER OF RUSSELL COUNTY, VIRGINIA, AND THE FACT OF SUCH PAYMENT APPEARS:

(ON THE FACE HEREOF BY THE SIGNATURE OF SUCH TREASURER HERETO.

‘COMNISSIONER OF THE REVENUE Date

TREASURER DATE