Form 330 - Tax Credit Summary And Certificate Request For Oil And Gas Production Tax Credits

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330
Alaska
Tax Credit Summary and Certificate Request
for Oil and Gas Production Tax Credits
under AS 43.55.023
Federal EIN
Date of Claim
Taxpayer Name
Mailing Address
City
State
Zip Code
Contact Person for Examination of Records
Title
Phone Number
Fax Number
Contact Email
Business Type
Corporation
Partnership
LLC
Sole Proprietor
Other ________
Check if this is an amended application and please provide the date of the original application _____________________
Production Tax Credits under AS 43.55.023
Certificate
Credit Amount Applied to
Production Tax Credits under AS 43.55.023
Credit Amount
Requested
Tax Liability
1 Credit balance under AS 43.55.023 carried over
(select
yes or
no)
from the previous year
2 AS 43.55.023(a)(1) credit for 20% on Schedule A
(select
yes or
no)
3 AS 43.55.023(I)(1) credit for 40% on Schedule A
(select
yes or
no)
4 AS 43.55.023(a)(2) credit for 20% on Schedule B
(select
yes or
no)
5 AS 43.55.023(I)(2) credit for 40% on Schedule B
(select
yes or
no)
6 AS 43.55.023(b) credit for 25% on Schedule C
(select
yes or
no)
7 AS 43.55.023(i) credit on Schedule D
0
8 Total lines 1-7
0
9 Tax Credit Requested as Transferable Tax Credit Certificate(s)
0
10 Adjustments to Transferable Tax Credit Certificate Claim (attach description
of each)
11 Total Tax Credit Requested as Tran ferable Tax Credit Certificate(s), line (9)
0
less line (10)
12 Credit balance under AS 43.55.023 carried over to next year (not converted
to certificates)
I declare under the penalty of perjury that the information provided in this application has been reviewed by me, and to the best
of my knowledge and belief is true, correct and complete. If prepared by a person other than the taxpayer, preparer’s declaration
is based on all information of which preparer has any knowledge. If a certificate is requested, the applicant certifies under
oath that the expenditures for which the credit is claimed have been incurred, that the credit has not been used, and that the
applicant is aware of no reason why the applicant does not qualify for the credit.
Printed Name and Title
Date
Signature
This form is available online at
Submit completed applications via the Tax Division’s Online Tax
Information System (OTIS) at
330
Mail to: Alaska Department of Revenue, 550 W 7th Ave STE 500, Anchorage AK 99501-3555
0405-330 Rev 03/19/13 - page 1

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