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This document is a statement of net proceeds form for vermiculite producers in Montana for the year ending December 31. It requires the producer to provide their name, address, FEIN number, account ID, period covered, tons of vermiculite extracted, value per ton, taxable value by multiplying tons by value, and a schedule of royalty interests including names, addresses, and amounts paid. The completed form is due by March 31 of the following year to the Montana Department of Revenue.

