R-9054-L Form Sev O-5 - Monthly Oil Well Report For Exempt Wells - State Of Louisiana Department Of Revenue

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R-9054-L (12/03)
State of Louisiana
O-5
FORM SEV
Department of Revenue
Page
________ of ________
Oil Severance Tax
P. O. Box 201, Baton Rouge, Louisiana 70821-0201
File original of this return only.
Monthly Oil Well Report for Exempt Wells
Reporting company name
Revenue account number
Reporting company address (including ZIP code)
Reporting company number
Taxable Period
Value for payout
Conservation Codes
Field name
Exempt
Production
Disposition
of well cost
Taxpayer
Producer name
Conservation
Parish
tax
(barrels)
(barrels)
(disposition barrels)
number
Lease and Well name
code
Field
Producer
Lease
rate code
well serial no.
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
This report must be filed with Form R-9015 (O-1d), Oil and/or Condensate Severance Tax Return – Lease Detail.

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