Form R-9010-L - Certification Of Continued Responsibility For Payment Of Oil Spill Contigency Fee - Louisiana Department Of Revenue

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R-9010-L (6/05)
Certification of Continued
Responsibility for Payment
of Oil Spill Contingency Fee
(R.S. 30:2451-2496)
Taxpayer Services Division
P.O. Box 201
Baton Rouge, LA 70821-0201
(225) 219-7656
(225) 219-2114 (TDD)
Revenue Account Number __________________________________________________________________
This certifies that __________________________________________________________________________
Name
Address
City
State
ZIP+4
________________________________________________________________________________________
Address
is registered with the Louisiana Department of Revenue as a marine terminal operator and agrees to remit to the Louisiana
Department of Revenue the oil spill contingency fee on all oil subject to the fee which is picked up from or delivered to:
________________________________________________________________________________________
Name
Address
City
State
ZIP+4
________________________________________________________________________________________
Address
By signing this certification, the terminal operator assumes responsibility for payment of the fee and becomes the party to
whom the Louisiana Department of Revenue will look for payment. The terminal operator accepting this certification should
retain it in his records until all applicable periods have prescribed. A copy must be furnished to the Louisiana Department
of Revenue.
Area code and telephone number
Signature
Date

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