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                                       Excise Tax on Certain Transfers of Qualifying    
Form     8924                                                                                                                              OMB No. 1545-2099
(Rev. December 2013)                                 Geothermal or Mineral Interests
Department of the Treasury  
Internal Revenue Service          ▶ Information about Form 8924 and its instructions is at www.irs.gov/form8924.
Name of entity                                                                                                                Employer identification number 

Number, street, and room or suite no. (If a P.O. box, see instructions) 

City or town, state or province, country, and ZIP or foreign postal code 

Tax Computation 

1        Date of sale or other disposition (MM/DD/YYYY)  .                 . .  .  .    .    . .   .      . . .   . .  .   .
2        If the property was sold or exchanged, enter the sales price of the interest transferred. If the
         property was leased, enter the income realized as a result of the transfer  .                    . . .   . .  .   .      2 

3        Cost or other basis of interest transferred. Enter -0- if the property was leased  .                 .   . .  .   .      3 

4        Gain or income realized. Subtract line 3 from line 2. If zero or less, enter -0-  .                . .   . .  .   .      4 

5        Fair market value of the interest transferred as of the date shown on line 1  .                    . .   . .  .   .      5 

6        Multiply line 5 by 20% (.20)  .           . . . .  .   .        . . .  .  .    .    . .   .      . . .   . .  .   .      6 

7        Multiply line 4 by 35% (.35)  .           . . . .  .   .        . . .  .  .    .    . .   .      . . .   . .  .   .      7 

8        Tax. Add lines 6 and 7   .       .        . . . .  .   .        . . .  .  .    .    . .   .      . . .   . .  .   .      8 

9        Tax paid with Form 7004 .        .        . . . .  .   .        . . .  .  .    .    . .   .      . . .   . .  .   .      9 

10       Tax due. Enter the excess, if any, of line 8 over line 9  .            .  .    .    . .   .      . . .   . .  .   .      10 

11       Overpayment. Enter the excess, if any, of line 9 over line 8  .                .    . .   .      . . .   . .  .   .      11 
               Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge
Sign           and belief, it is true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge. 
               ▲
Here 
                   Your signature                                                            Date                                 Title 
               Print/Type preparer’s name                   Preparer's signature                              Date
Paid                                                                                                                          Check         if PTIN
                                                                                                                              self-employed
Preparer                       ▶                                                                                              Firm's EIN ▶
               Firm's name     
Use Only                       ▶                                                                                              Phone no.
               Firm's address  
For Paperwork Reduction Act Notice, see instructions.                                        Cat. No. 37736P                           Form 8924 (Rev. 12-2013) 

Section references are to the Internal  Revenue          • A conservation sale in which the previous              When To File 
Code.                                                    transferor excluded 25% of the qualifying gain,          File Form 8924 by the 90th day following the 
                                                         or 
Future Developments                                                                                               taxable transfer. If you need more time to file, 
For the latest information about developments            • A transfer in which the previous  transferor was       use Form 7004, Application for Automatic 6-
related to Form 8924 and its instructions, such          relieved of liability for the  Form 8924 tax.            Month Extension of Time To File Certain 
                                                                                                                  Business Income Tax, Information, and Other 
as legislation enacted after they were published,        Relief from liability. An eligible entity is  not        Returns, by the due date of Form 8924. Form 
go to www.irs.gov/form8924.                              required to file Form 8924 if:                           7004 does not extend the time for payment of 
General Instructions                                     • The transferee is an eligible entity which             tax. 
                                                         provides the transferor with a qualifying  letter of 
Purpose of Form                                          intent at the time of the transfer,                      Amended Return 
Use Form 8924 to report and pay the  excise tax          • The transferee is not an eligible entity but           To amend a previously filed Form 8924, file  a 
on certain transfers of qualifying  geothermal or        establishes to the satisfaction of the  Secretary of     corrected Form 8924 and write  “Amended” at 
mineral interests.                                       the Treasury that the transfer  of ownership or          the top of the form. 
Who Must File                                            possession will be  consistent with section 170(h)       Where To File 
                                                         (5) and  provides the transferor with a qualifying  
An eligible entity who subsequently  transfers           letter of intent at the time of the transfer, or         Send Form 8924 to the following address.
ownership or possession (by sale,  exchange, or 
lease) of a qualifying mineral  or geothermal            • Form 8924 tax has previously been paid  as a             Department of the Treasury 
interest must file Form 8924  for each transfer of       result of a previous transfer of  ownership or             Internal Revenue Service Center 
an interest acquired,  directly or indirectly, in:       possession of the same  interest.                          Cincinnati, OH 45999



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Form 8924 (Rev. 12-2013)                                                                                                                            Page  2 

Rounding Off to Whole  Dollars                      Environmental Impact Statement and that is           Paid Preparer Use Only
You may show money items on the return  as          located from T. 31 N. to T. 16 N. and R. 13 W. 
whole dollars. To do so, drop any  amount less      to R. 7 W.; and                                      A paid preparer must sign Form 8924 and 
                                                                                                         provide the information in the Paid Preparer Use 
than 50 cents and increase  any amount from 50      • Within the Badger Two Medicine Area of  the        Only section at the end of the form if the preparer 
cents through 99  cents to the next higher dollar.  Flathead National Forest including the  land         was paid to prepare the form and is not an 
                                                    located in T. 29 N. from the western  edge of R.     employee of the filing entity. The preparer must 
Signature                                           16 W. to the eastern edge of R.  13 W., and the      give you a copy of the form in addition to the 
See the instructions for the signature  section of  land located in T. 28 N., Rs. 13, and 14 W.          copy to be filed with the IRS.
your federal income tax return.                     Qualifying letter of intent. A qualifying  letter of    If you are a paid preparer, enter your Preparer 
Interest and Penalties                              intent means a written letter of  intent that        Tax Identification Number (PTIN) in the space 
Interest. Interest is charged on taxes not  paid    includes the following statement.                    provided. If you work for a tax preparation firm, 
by the due date at a rate determined  under         “The transferee’s intent is that this  acquisition   you must also enter the firm's name, address, 
section 6621.                                       will serve one or more of the  conservation          and EIN. However, you cannot use the PTIN of 
Late filing of return.A penalty of 5% a  month      purposes specified in clause  (i), (ii), or (iii) of the tax preparation firm in place of your PTIN. 
or part of a month, up to a  maximum of 25%, is     section 170(h)(4)(A) of the  Internal Revenue           You can apply for a PTIN online or by filing 
imposed on the net  amount due if Form 8924 is      Code of 1986, that the  transferee’s use of the      Form W-12, IRS Paid Preparer Tax Identification 
not filed when due.                                 deposits so acquired will be consistent with         Number (PTIN) Application and Renewal. For 
                                                    section 170(h)(5) of such Code, and that the use     more information about applying for a PTIN 
Late payment of tax. Generally, the  penalty for    of the deposits will continue to be consistent       online, visit the IRS website at www.irs.gov/ptin.
not paying tax when due is 1/2  of 1% of the        with such section, even if ownership or 
unpaid amount, up to a  maximum of 25%, for         possession of such deposits is subsequently          Paperwork Reduction Act Notice. We ask for 
each month or part  of a month the tax remains      transferred to another person.”                      the information on this form to carry out the 
unpaid. The  penalty is imposed on the net          Qualifying mineral or geothermal  interest. A        Internal Revenue laws of the United States. You 
amount due.                                         qualifying mineral or geothermal  interest means     are required to give us the information. We need 
Definitions                                         an interest in any mineral or  geothermal deposit    it to ensure that you are complying with these 
Bureau of Land Management land. This  term          located on eligible  federal land that constitutes   laws and to allow us to figure and collect the 
means the Bureau of Land  Management land           the transferor’s entire interest in the deposit.     right amount of tax. Section 6109 requires return 
and any federally-owned  minerals located south     An interest in any mineral or geothermal is not      preparers to provide their identifying numbers on 
of the Blackfeet  Indian Reservation and east of    the transferor’s entire interest if the interest in  the return. 
the Lewis  and Clark National Forest to the         that mineral or geothermal deposit was divided in       You are not required to provide the  
eastern  edge of R. 8 W., beginning in T. 29 N.     order to avoid the requirements of a qualifying      information requested on a form that is  subject 
down to and including T. 19 N. and all of  T. 18    mineral or geothermal interest or section 170(f)(3)  to the Paperwork Reduction Act  unless the form 
N., R. 7 W.                                         (A).                                                 displays a valid OMB  control number. Books or 
Conservation sale. A conservation sale  means       The transferor’s entire interest in such deposit     records relating  to a form or its instructions must 
a sale which meets the following  requirements.     does not fail to be a qualifying mineral or          be  retained as long as their contents may  
• The transferee of the qualifying mineral or       geothermal interest solely because the transferor    become material in the administration of  any 
geothermal interest is an eligible entity.          has retained an interest in other deposits, even if  Internal Revenue law. Generally, tax  returns and 
                                                    the other deposits are contiguous with such          return information are  confidential, as required 
• At the time of the sale, the transferee  provides certain deposit and were acquired by the             by section 6103. 
the transferor with a qualifying  letter of intent. transferor along with such certain deposit in a         The time needed to complete and file this form 
• The sale is not made under an order of            single conveyance.                                   will vary depending on individual circumstances. 
condemnation or eminent domain.                                                                          The estimated average time is:
                                                    Specific Instructions 
Eligible entity. An eligible entity means:                                                               Recordkeeping     .   .   . .    .  4 hr.,  4 min. 
• A governmental unit referred to in section        Name and address. Enter the name shown on            Learning about the law   
                                                    the eligible entity’s most recently filed federal    or the form   .   .   .   . .    .   .   .  42 min. 
170(c)(1) or an agency or department thereof        income tax return. If the Post Office does not 
operated primarily for one or more of the           deliver mail to the street address and the entity    Preparing, copying, assembling, and 
conservation purposes specified in section170(h)    has a P.O. box, show the box number instead of       sending the form to the IRS      .   .   . 47 min. 
(4)(A)(i), (ii), or (iii), or                       the street address.                                     If you have comments concerning the  
• An entity that is described in section  170(b)(1) Foreign Address. Follow the country's practice       accuracy of these time estimates or  suggestions 
(A)(vi) or section 170(h)(3)(B) and  organized and  for entering the postal code. In some countries      for making this form simpler,  we would be happy 
at all times operated  primarily for one or more of the postal code may come before the city or          to hear from you. You can send your comments 
the conservation purposes specified in section      town name. Enter the full name of the country        from www.irs.gov/formspubs/. Click on “More 
170(h)(4)(A)(i), (ii), or (iii).                    using uppercase letters in English.                  Information” and then on “Comment on Tax 
Eligible federal land. The term eligible  federal                                                        Forms and Publications.” You  can also write to:
land means the Bureau of Land  Management           Tax Computation                                      Internal Revenue Service 
land and the Forest Service  land, as generally     Line 10                                              Tax Forms and Publications 
depicted on the map  entitled “Rocky Mountain       The tax due must be paid in full when  Form          1111 Constitution Ave. NW, IR-6526 
Front Mineral Withdrawal Area” and dated            8924 is filed. Make the check or  money order        Washington, DC 20224
January 8,  2007. You can view an  electronic       payable to “United States  Treasury.” Write the         DO NOT send the tax form to this  address. 
version of the map at www.fs.fed.us/land/staff/     entity’s name,  address, employer identification     Instead, see Where To File, earlier. 
rocky_mtn_front_withdrawal.shtml.                   number,  and “Form 8924” on the check or 
Forest Service land. This term means the            money  order. 
Forest Service land and any federally-owned 
minerals located:                                   Line 11 
• In the Rocky Mountain Division of the Lewis       The IRS will refund the amount on line 11 if  no 
and Clark National Forest, including the            other taxes are owed. 
approximately 356,111 acres of land made 
unavailable for leasing by the August 28, 1997, 
Record of Decision for the Lewis and Clark 
National Forest Oil and Gas Leasing






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