Form 0405-662 - Mining License Tax Return - 2013 Page 6
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2
3
4
5
6
7662
Name of Taxpayer or Business
Mining License #
Description and Location of Mining Operation
Page 6
Schedule F - Royalties Received from Operator/Lessee (see instructions)
Name and Address of each Lessee
Amount Received
1
Federal ID
FEIN
SSN
Name
$____________________
Mailing Address
City
State
Zip Code
2
Federal ID
FEIN
SSN
Name
$____________________
Mailing Address
City
State
Zip Code
3
Federal ID
FEIN
SSN
Name
$____________________
Mailing Address
City
State
Zip Code
4
Federal ID
FEIN
SSN
Name
$____________________
Mailing Address
City
State
Zip Code
5
Federal ID
FEIN
SSN
Name
$____________________
Mailing Address
City
State
Zip Code
Total royalties received. Add amounts received and enter here and on Schedule A, line 2 of the
6
appropriate mining operation.
662
0405-662 Rev 10/04/13 - page 6
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