HomeMy WebLinkAbout20192042.tiffBAYSWATER EXPLORATION & PRODUCTION, LLC
73c 7TH STREET, SUITE 500 • DENVER, CO 80202 • 303-893-2503
CHECK NO. 099839
1905 -AP -222 05/21/19 CHKREQRG052 110.14
119
REFUND SEVERANCE TAXES WITHHELD IN ERROR
0.00 110.14
RECEIVED
MAY 2 4 2039
rn MI COUNTY
S
2019-2042
L -S o l40
2227 WELD COUNTY
05/22/19 110.14
rant n_lnn
DR 21-w COLORADO DEPARTMENT OF REVENUE
INSTRUCTIONS FOR PREPARING FORM DR 21w
Box 1-5 Enter the information requested.
Line 6 Enter the total gross payments made to the interest
owner on both cash basis and accrual basis. For cash
basis, report all payments made during the year even
if they are for prior period production or are take
or pay payments for future production. For accrual
basis, report payments on all production during the
calendar year, even if they are not disbursed to the
interest owner within the year.
Line 7 Enter that portion of payments, on both the cash and
accrual basis, that are for tax exempt oil production
from a stripper well.
Line 8 Enter the amount of ad valorem tax on both cash and
accrual basis. For cash basis, report only ad valorem
taxes actually paid to the county assessors during the
year. For accrual basis, report the actual ad valorem
tax amount assessed at the mill levy date (usually in
November of December) within the year.
Line 9 Enter the amount of ad valorem tax for both the cash
and accrual basis that related to the oil production
from a stripper well.
Line 10 Enter amount of severance tax actually withheld and
remitted to Colorado Department of Revenue for the
calendar year.
Box 11 (Si 12 Enter information as required.
INSTRUCTIONS FOR RECIPIENTS OF FORM DR 21w
Any producer, working, royalty or other interest owner of oil
and gas produced in Colorado is required to pay severance tax.
Every producer of first purchaser is required to withhold 1% of
the gross income paid to every owner, and to supply an oil and
Gas withholding Statement by March 1 of each year.
This oil and Gas withholding statement form lists your gross
income from the property indicated and the amount the producer
or first purchaser has withheld. It also lists your share of
any ad valorem taxes paid.
You must attach one copy of this form to your "Colorado
Severance Tax Return" (DR 0021) in order to claim credits. If
you need additional information about severance tax order
FYI -General #4 Severance Tax Information for Owners of any
interest in any oil and Gas (Including Carbon Dioxide Produced
in Colorado) from the Department of Revenue by phoning the
Forms order Hot Line (303)232-2414 or via the internet at
http:/www.revenue.state.co.us
RECEIVED
M:AR
WELD COUNTY
COMMSSIoNFPc
DR 21-w COLORADO DEPARTMENT OF REVENUE
DENVER CO 80261-0005 OIL AND GAS WITHHOLDING STATEMENT FOR CALENDER YEAR 2018
COLORADO SEVERANCE TAX WITHHELD FROM OIL SHALE AND OIL/GAS PAYMENTS
Owner No..'fi''':f'" Owner Tax Id. 846000813
1. well Name:
2. Lease:
3. Field:
6. GROSS PAYMENTS
7. GROSS PAYMENTS ATTRIBUTABLE TO STRIPPER WELL PRODUCTION
8. AD VALOREM TAX ON OIL AND GAS PRODUCTION
9. AD VALOREM TAX ATTRIBUTABLE TO STRIPPER WELL PRODUCTION
10. SEVERANCE TAX WITHELD
4. County:
S. Colorado Oil and Gas Conservation
Commission Lease Number:
CASH BASIS
$10,972.29
$9,549.90
$603.53
$525.27
$109.71
(or"'
ACCRUAL BASIS
$10,846.77
$10,846.77
$383.68
$383.68
- - # d H.3 kil-/
Vig
If filing on a fiscal period, this information is not correct. Consult your distribution statements or payor for correct amounts.
11. Name, Address & Social Security or Colorado Acct No of Payee: 12. Name, Address & Colorado Acct No or Federal I.D. No of Payor:
May 6, 2019
flECEIVE
MAY 13 2019
lit
Bayswater Exploration & Production
730 17th Street
Denver, CO 80202
RE: Withholding Taxes
CLERK TO THE BOARD
1150 O STREET
P.O. BOX 758
GREELEY, COLORADO 80632
PHONE: 970-400-4225
FAX: 970-352-0242
Enclosed please find a copy of our Sales Tax Exemption Certificate. As a county government, we
are tax exempt from ad valorem and severance taxes. According to the enclosed statement, you
are withholding taxes on one or more of our leases. Please correct your records so taxes are
not withheld in the future. Also, please refund the taxes withheld and send to Clerk to the Board,
Weld County Government, Attention Jessica Reid, P.O. Box 758, Greeley, Colorado, 80632.
If you have questions or need additional information, please do not hesitate to contact me at.
(970) 400-4212.
Sincerely,
Jessica Reid
Deputy Clerk to the Board
jreidaweldgov.com
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