R-9023 (10/05)
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If your address has
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Account ID (10 digit BMF #)
Oil and/or Condensate
Parish Summary (01-S)
Address 1
Louisiana Department of Revenue
Address 2
P.O. Box 201
Address 3
Baton Rouge, Louisiana 70821-0201
(225) 219-7656
Address 4
(225) 219-2114 (TDD)
Reporting Company ID (5 digit Severance #)
FOR OFFICE USE ONLY.
Field flag
Taxable
period
Summary
Tax Rate
Taxable Barrels
Tax Amount Due
Code
% of Value
Totals, Full Rate-Oil & Condensate
1
12.5%
$
Totals, Half Rate-Incapable Oil
2
6.25%
$
Totals, Quarter Rate-Stripper Oil
3
3.125%
$
Totals, Reclaimed Oil
9
3.125%
$
Produced Water Injection Incentive – Approved Projects Only
Totals, Produced Water-full Rate
1P
10.0%
$
Totals, Produced Water-Incapable Oil Rate
2P
5.0%
$
Totals, Produced Water-Stripper Oil Rate
3P
2.5%
$
Total interest and penalty
6
$
GRAND TOTAL
$
Under the penalties of perjury, I declare that I have examined this return, including all accompanying documents, and to the best of my knowledge and belief, it is true, correct, and complete. If the
return is prepared by a person other than the taxpayer, his declaration is based on all the information relating to the matters required to be reported in the return of which he has any knowledge.
Preparer ID
Date
Signature of preparer other than taxpayer
Signature
Telephone Number
This return is due on or before the 25
th
day of the second month following the taxable period and becomes delinquent the first day thereafter. If
due date falls on a weekend or holiday, the return is due on the first business day following the due date and becomes delinquent the first day
thereafter. See special instructions for additional filing requirements for taxpayers with liabilities equal to or in excess of $15,000.
Complete only if change in business status has occurred. Please print or type.
Date business sold
Name of purchaser
Date business discontinued
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