Indiana Department of Revenue MF-600 Petroleum Severance Tax Return State Form 11874 (R5 / 9-12) For the month of _____________, 20______ Name Mailing Address City License Number State Zip Code Federal Identification Number Table 1: Crude Oil Date Purchased or Gathered Unit Price Per Barrel A. Quantity Gathered Or Purchased (#Barrel) B. Value of Product (Price x Quantity) C. Indicate Column A x $.24 Per Barrel or Column B x 1% Whichever is Greater Total of Column C. Table 2: Natural Gas Date Purchased or Gathered Unit Price Per MCF A. Quantity Gathered or Purchased (#MCF) C. Indicate Column A x $.03 per MCF or Column B x 1% Whichever is Greater B. Value of Product (Price x Quantity) Total of Column C. 1. Indicate the total amount of Crude Oil from Table 1, Column C. 1 2. Indicate the total amount of Natural Gas from Table 2, Column C. 2 3. Tax Due: Indicate the total of line 1 plus line 2. 3 + 4. Plus or minus money adjustment (attach full explanation). - 4 5. Adjusted tax due (line 3 plus or minus line 4). 5 6. Penalty (Penalty must be added if report is filed after the due date. Penalty is 10 percent (.10) of tax due or $2, whichever is greater. $2 is due on a late return showing no tax due.) 6 7. Interest (Interest must be added if filed after the due date. 7 8. Total amount due (add lines 5, 6, and 7). Enclose your remittance for this amount. Contact the Department for the daily interest rates.) For Department Use Only Check Check Amount: Number: 8 Make check payable to Indiana Department of Revenue and mail to: P.O. Box 6080, Indianapolis, IN 46206-6080. Under penalty of perjury, I declare that I have examined this return, including accompanying schedules and statements, and, to the best of my knowledge and belief it is true, correct, and complete. I further declare that complete and proper records are on file at the address indicated above for all fuel reported on this return. Taxpayer or Authorized Agent □ Title Date Signed Please Check Box If Last Filing Type or Print Name Telephone Number Date Business Closed American LegalNet, Inc. www.FormsWorkFlow.com Instructions for Completing the Petroleum Severance Tax Reporting Forms Under the provisions of the Indiana Petroleum Severance Tax Law (Indiana Code 6-8-1-8) states: A tax at a rate equal to the greater of: (1) (2) one percent (1%) of the value of the petroleum; or three cents (.03) per thousand (1,000) cubic feet (MCF) for natural gas and twenty-four cents (.24) per barrel for oil; The severance tax is to be reported by all purchasers of petroleum products or gatherers of petroleum products at the time such products are transported from the place of production. The purchaser or gatherer is imposed with the responsibility to make reports of the severance of petroleum products from the land and the payment of the tax thereupon for and on behalf of the owner or producer of the products as their interests may be. Reporting Forms is hereby imposed as of the time of the severance for such petroleum from the land, upon all producers and owners thereof... Product producers or gatherers are to report their severance activities and the amounts of tax due thereon each month by using the Petroleum Severance Tax Reporting Form #1 (Form MF-600). “Value” means the price paid for such petroleum products or their market value at the time of severance if gathered for consumption by the severing party. The tax is imposed at the time of sale or delivery from the place of production. Consequently, no transportation or freight allowances are to be used when determining the reporting value of the product for tax purposes. The completed form and remittance of tax due should be mailed to: Indiana Department of Revenue P.O. Box 6080 Indianapolis, IN 46206-6080 “Petroleum” subject to the severance tax means and includes crude petroleum oil and gas, and other hydrocarbons, whether in liquid or gaseous form and regardless of gravity, which are severed from the land and produced from a well in the State of Indiana. Any questions about these reporting requirements should be directed to the Fuel Tax Section. Telephone inquiries about the Petroleum Severance Tax should be directed to (317) 615-2630. Reporting Requirements Reports of severance activities are to be filed with the Fuel Tax Section within thirty (30) days after the last day of the calendar month being reported. Reports filed late will be subject to statutory penalty and interest charges. American LegalNet, Inc. www.FormsWorkFlow.com