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COAL SEVERANCE AFFIDAVIT
Company Name Mine Name
Operator’s Name Mite Index #
Owner’s Name County
‘Tons Mined
Company Name
Operator’s Signature
Subject to any supplemental assessment made pursuant fo an audit, this is to certify that
the above named operator has paid all local coal license taxes pursuant to Section 45.1-
21(1), 58.1-3712 and 58.1-3713 of the Code of Virginia.
Date Russell County Commi:

of the Revenue

Subject to any supplemental assessment made pursuant to an audit, this is to certify that
the above named operator, as of this date, has paid all personal property (including
merchants capital and/or machinery and tools) real estate and mineral land taxes
associated with this mining operation in accordance with 45.1-21 of the Code of Virginia,
as amended.
Date ‘Treasurer of Russell County