Form R-9004 - Oil Spill Contingency Fee Quarterly Return
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2R-9004 (7/10)
Oil Spill Contingency Fee Quarterly Return
(R.S. 30:2451–2496)
Special Program Division
Severance Tax Section
P.O. Box 201
Baton Rouge, LA 70821-0201
This return is due on or before the last
day of the first month following the taxable
period and becomes delinquent on the first
Account number
__________________________________________
day thereafter. If the due date falls on a
Name
__________________________________________
weekend or holiday, the return is due the
next business day and becomes delinquent
Address
__________________________________________
the first day thereafter.
City, State, ZIP
__________________________________________
Quarter Ending
Select a Quarter
1 Number of barrels of crude oil unloaded from a vessel
a Domestic (Louisiana)
b From other states
c Foreign
d Total (Add Lines 1a, 1b, and 1c.)
‹
›
e Less barrels on which other operators are paying fee (See Schedule A on back.)
f Net total (Subtract Line 1e from Line 1d.)
2 Number of barrels of crude oil loaded onto a vessel
a Louisiana destination
b For export to other states
c For export to foreign countries
d Total (Add Lines 2a, 2b, and 2c.)
‹
›
e Less barrels on which other operators are paying fee (See Schedule A on back.)
f Net total (Subtract Line 2e from Line 2d.)
3 Total of Lines 1f and 2f
4 Multiply Line 3 by $0.02.
‹
›
5 Less vendor’s compensation (1.5% of Line 4 if timely filed)
6 Net fee due
7 Delinquent penalty
(5% for each 30 days or fraction thereof from due date of payment, not to exceed 25%)
8 Interest (See instructions.)
9 Total amount due
(Make payment to: Louisiana Department of Revenue. Do not send cash. Pay this amount.
u
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
Telephone
Date
5507
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