This document is a Montana Resource Indemnity Trust Tax form for metal mines. It requires mines to report information like the mine name, location, owner, tons of ore extracted, and value of metals produced. Mines must provide production quantities and values for metals like copper, gold, silver, and zinc. The form then calculates the total gross value, tax owed based on 0.5% of gross value, and any penalties or interest due. It must be signed and dated by an authorized representative of the mine.