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MAIL RETURN & PAYMENT TO:
COMMISSIONER OF THE REVENUE
PO BOX 517
LEBANON, VA 242656
MAKE CHECKS PAYABLE TO:
‘TREASURER OF RUSSELL COUNTY
MONTHLY RETURN
TO SEVER COAL GASES, OR OIL FROM LANDS
‘SITUATED IN RUSSELL COUNTY, VIRGINIA
For the calendar month of , Year,
OPERATOR’S NAME: TELEPHONE#: |
ADDRESS:
cry: STATE: ZIP:
COAL:
MINE NAME & NUMBER: MINE INDEX #:
MINE TYPE: DATE OPERATION BEGAN AT THIS LOCATION:
DMLR #: MSHA #: PREVIOUS MINE INDEX NUMBER:
GAS / OIL: WELL TYPE (CHECK ONE): Q GAs Q OIL Q LIQUID GAS
OPERATIONSNAME: DMME APPLICATION
TYPE OF OPERATION; _ DMME FILE NUMBER:
WELL COMPLETION DATE: DEPTH OF WELL:
UE ON OR TH mIeTH (20
IT IS REQUIRED THAT YOU FILE A RETURN WITH OUR OFFICE EACH MONTH.
DAY OF EACH MONTH IMMEDIATI TH WERE SEVERED. A RETURN THAT IS NOT FILED
TIMELY SHALL INCUR A PENALTY OF 10%, PLUS INTEREST AT THE RATE OF 5% PER ANNUM. FAILURE TO FILE THE MONTHLY RETURN
AND TO PAY THE APPLICABLE TAXES BY THE TWENTIETH (20) DAY OF THE MONTH IMMEDIATELY FOLLOWING THE MONTH IN WHICH
‘THE MINERALS WERE SEVERED MAY RESULT IN A SUSPENSION OF YOUR LICENSE,
‘GROSS TONS |= GROSS] SNES]
Tgenge | SEVERED FOR | Recelprs ron | pice rer | sasis PENALTY | rerest | BALANCE DUE
“THE MONTH | iE MONTH: nae 2 zi
COAL
SEVERANCE 2%
GROSS MCF °F GROSS A]: SALE >
TEESE | seteneoFon | recerteron | eniceren | ease | tax | PMA’ | meres | pacance ous
THE MONTN. | “imeMONTN’| © Mice :
as
‘SEVERANCE 3%
cen EPP
ca eros |" sate :
report. | eames | pect petites [aan | tax | PematTY | wreneor | pauanos ous
_THE MONTH ‘THE MONTH."=|° BARREL®.| 2
OL a
sevetince 05%
TOTAL
PAYMENT:
OATH: 1, THE UNDERSIGNED AGENT, DO SWEAR (OR AFFIRM) UNDER PENALTY OF PERJURY, THAT THE FOREGOING FIGURES AND
STATEMENTS ARE TRUE, CORRECT, AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND BELIEF, AND THAT TAM
AUTHORIZED TO FILE THIS RETURN.
‘Signature of Operator or Authorized Agent Operator or Agent’s Name (Prini) Title
SWORN (OR AFFIRMED) ON THIS DAY OF 20, ‘TELEPHONE NUMBER:
EMAIL ADDRESS: . FAX NUMBER:
"THIS RETURN SHALL NOT BE VALID OR HAVE ANY LEGAL EFFECT UNLESS AND UNTIL THE TAXES PRESCRIBED BY LAW (AND ANY APPLICABLE PENALTIES AND
INTEREST). AS SHOWN ON THE FOREGOING RETURN, ARE PAID TO THE TREASURER OF RUSSELL COUNTY, VIRGINIA, AND THE FACT OF SUCH PAYMENT APPEARS:
(ON THE FACE HEREOF BY THE SIGNATURE OF SUCH TREASURER HERETO.
‘COMNISSIONER OF THE REVENUE Date
TREASURER DATE