Form R-9050 - Oilfield Site Restoration Fee Return Oil And Condensate Production - Louisiana Department Of Revenue

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R-9050 (7/06)
Oilfield Site Restoration
Fee Return
Oil and Condensate Production
Account Number
Louisiana Department of Revenue
Taxpayer Services Division
Name(1)
PO Box 201
Name(2)
Baton Rouge, LA 70821-0201
Address(1)
O/C
Address(2)
City
State
ZIP
FOR OFFICE USE ONLY.
Mark here if
Mark here if name or address
amended return.
has changed and correct label.
For the quarter ended: ______________________
Fee rate
Amount
Barrels
per barrel
of fee
,
,
,
,
00
x
.015 ..........1b
1a. Full rate
●
2a. Incapable
,
,
,
,
00
x
.0075 ........2b
rate
●
,
,
3a. Stripper
,
,
00
x
.00375 ......3b
●
rate
,
,
00
4. Total fees (Add Lines 1b, 2b, and 3b.) ......................................4
●
,
,
00
5. Interest (See instructions.)..........................................................5
●
6. Delinquent penalty (5% for each 30 days or fraction thereof,
,
,
00
not to exceed 25% of Line 4) ......................................................6
●
➧
Pay this
,
,
00
amount.
●
7. Total fees, interest, and penalty due ..........................................7
Make payment to: Louisiana Department of
Revenue. Do not send cash.
This return is due on or before the 25
th
day of the second month following the taxable period and becomes
delinquent on the first day thereafter. If the due date falls on a weekend or holiday, the return is due the next
business day and becomes delinquent the first day thereafter.
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.
Signature
Date
Type or print name
Telephone
5500

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