Form 8401 - Wyoming Annual Gross Products Report For Bentonite Page 7
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7State of Wyoming
ANNUAL GROSS PRODUCTS REPORT
8401
Department of Revenue
FOR BENTONITE
122 West 25th Street
*8401*
Cheyenne, WY 82002-0110
Production Year:
TAXPAYER INFORMATION
__ __ __ __
Operator
Revenue Use Only
MINE INFORMATION
Taxpayer
Mine Group Number
Contact Person / Agent
Telephone Number
Mine Group Name
Address
DEQ Permit Number
City
State
Zip
County
O = Original
Form Type:
A = Amended
Production and Taxable Value for Bentonite Sold Away from the Mouth of the Mine
1. Total Wet Tons Mined
tons
6. Direct Mining Costs
$
$
$
2. Private Royalty Value
7. Direct in-mine transportation costs
$ / ton
$
3. Private Royalty Value per ton
8. Total Direct Mining Cost
(line 2 / line 1)
(line 6 + line 7)
$ / ton
9. Total Direct Mining Cost per ton
(line 8 / line 1)
4a. Severance Taxes
$
$
4b. Gross Products Taxes
10. Add-on Factor
.
$
4. Total Production Taxes
(line 4a + line 4b)
$ / ton
5. Production Taxes per ton
(line 4 / line 1)
$ / ton
11. Total Direct Mining Cost per ton x Add-on Factor (Line 9 x Line 10)
12. Taxable Value Per ton (line 3 + line 5 + line 9 + line 11)
$ / ton
tons
13. Total Wet Tons Mined
$
14. Taxable Value of Bentonite Sold Away from Mine Mouth (line 12 x Line 13)
Production and Taxable Value Summary
tons
Taxable value
tons
15. Production and Taxable Value of Mine Mouth Sales
$
(line 4 and line 7 from mine mouth sales attachment)
tons
16. Production and Taxable Value of Bentonite Sold Away
$
from Mouth of the Mine (lines 13 and 14 above)
tons
17. Total Production and Taxable Value
$
(Line 15 + Line 16)
I declare under penalty of perjury that I have examined this return, and , to the best of my knowledge and belief, it is correct and complete.
MTS2
2/06/10
Authorized Signature
Title
Date
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