SEVERANCE TAX REPORT FOR SAND & GRAVEL                          Reporting Number (Mine Group Number): Enter the Mine 
 (Form 5400) INSTRUCTIONS (revised 9/2019)                       Group  Number  (the  5-digit  number  beginning  with  a  9) 
                                                                 assigned by the Department of Revenue. If you are reporting 
WHO MUST FILE - All taxes on production shall be remitted        a mine group which has not been assigned a Mine Group 
by the operator or his duly authorized agent. Severance          Number, leave this box blank. 
taxes  are  determined  from  the  gross  production  in  the     
current calendar year.                                           Tons Sold and Used: Enter the tons of sand and gravel sold 
                                                                 and  used.    This  would  include  both  pit  run  tons  and 
WHEN TO FILE  -  This report  must be received by the            processed tons produced during the production period.  This 
                                    th
Department on or before February 25  of the year following       figure should match the figure on Line 6 of Form 8601. 
the year in which production occurred.  Monthly reporting         
and payment requirements for sand and gravel production          Sales Value: Enter the sales value of sand and gravel sold.  
are waived, and the taxpayer shall report and pay the tax        This figure should match the total of Line 1 + Line 3 on Form 
                                 th
annually on or before February 25 .                              8601. 
                                                                  
TAX DUE    - If this report shows tax due, the taxpayer shall    Tons Mined: Enter the tons of sand and gravel mined during 
pay the tax due when the report is filed.  If the taxpayer does  the production period. This figure should match Line 7 on 
not pay the total tax due, that amount is delinquent and is      Form 8601. 
subject to penalty and interest.                                  
                                                                 Total Taxable Value: Enter the taxable value of the sand 
FOR  ASSISTANCE  -  For  assistance  with  any  Wyoming          and gravel mined during the production period.  This figure 
solid  mineral  tax  question,  please  call  the  Mineral  Tax  should match Line 11 on Form 8601. 
Division of the Department of Revenue at (307) 777-7983.          
                                                                 Total Tax Due: Enter the result of multiplying the Taxable 
GENERAL INSTRUCTIONS - For the purpose of mineral                Value by 2%, rounded to 2 decimal places (for example, 
taxation,  “sand  &  gravel”    includes  aggregates  used  in   $100.12). 
construction.    Please  complete  a  Severance  Report For       
Sand & Gravel (Form 5400) for each mine, using calendar          Previous Tax Paid (amends): For amended reports only. 
year production, sales, and cost information.  All sales and     Report the severance tax previously paid for this line item. If 
cost  information  provided  should  be  determined  on  the     this is an original report, enter 0. 
accrual basis of accounting, in accordance with generally         
accepted accounting principles.  Round all figures to the        Current Tax Due: Enter the result of subtracting Previous 
nearest whole number except where otherwise instructed.          Tax Paid from Total Tax Due. 
Fill out the report completely.  If the report is not filled out  
completely and accurately, the report may be considered          Page Total: Enter the sum of the Current Tax Due column on 
delinquent and may be subject to penalty and interest.  For      this Form 5400.  
additional information on the valuation of sand & gravel,         
refer to Wyoming Statute 39-14-601.                              Payment Amount:  Enter the amount of the payment being 
                                                                 sent with the report being filed. 
The  Department  recommends  that  you  complete  your            
Annual Gross Products Report For Sand & Gravel (Form             ADJUSTMENTS  TO  PREVIOUS  PRODUCTION  YEARS 
8601)  before  attempting  to  complete  this  severance  tax    MUST  BE  REPORTED  ON  AN  AMENDED  ANNUAL 
report (Form 5400).  The computation of taxable value and        GROSS  PRODUCTS  REPORT  (FORM  8601)  AND  AN 
tax due on this From 5400 is based on the information            AMENDED SEVERANCE FORM (FORM 5400).  DO NOT 
reported on Form 8601.                                           INCLUDE  PRIOR  YEAR  ADJUSTMENTS  IN  YOUR 
                                                                 CURRENT YEAR REPORTS.  
Operator ID: Enter the operator ID number (the 4-digit number     
beginning with a 9) assigned to you by the Department of         The  mailing  address  for  Department  of  Revenue  mineral 
Revenue. If an operator ID has not been assigned to you,         forms is: 
leave this box blank.                                             Wyoming Department of Revenue - Mineral Tax Division 
                                                                            Herschler Building, 3rd Floor East 
Taxpayer Name: Enter the Operator Name. Do not enter the                    Cheyenne, WY  82002-0110 
name of the contact person or tax agent. 
 
Production Period: Enter the production period (month and 
year of the production reported). For sand and gravel this 
will  be  December  of  the  previous  year  (for  example, 
12/2000).  
 
Form Type: Indicate if the report filed is an original (O) or an 
amended (A) report. Do not report original and amended line 
items on the same Form 5400. 
 

State of Wyoming 
Department of Revenue                   SEVERANCE TAX REPORT                                   5400 
122 West 25th Street 
Cheyenne WY 82002-0110                  FOR SAND & GRAVEL                                      *5400* 
         DOR USE ONLY: 
                           
Operator ID:                          Operator Name:                                                                                                               

Contact Name:                                          Contact Phone #:  (         ) 

                                                              O - Original     
Prod. Period:           /               Form Type:            A - Amended 
 MINE       TONS   SOLD    SALES  VALUE TONS  MINED  TAXABLE  VALUE TOTAL  TAX  DUE  PREVIOUS                                                            CURRENT 
 GROUP           AND USED                                                            TAX  PAID                                                           TAX  DUE 
 NUMBER                                                                              (AMENDS) 

                                                                             PAGE TOTAL:                                                                           
 REPORT INFORMATION FOR THE CALENDAR YEAR                                                     
                     FOR EACH MINE GROUP NUMBER                              PAYMENT AMOUNT: 
                                                                                                                                                                   
            I declare under penalty of perjury that I have examined this return and, to the best of my knowledge and belief, it is correct and complete. 

                 Authorized Signature                               Title                                                                                Date 
REV.2/2000