Form R-9050 - Oilfield Site Restoration Fee Return

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R-9050 (6/04)
Louisiana Department of Revenue
Taxpayer Services Division
PO Box 201
Baton Rouge, LA 70821-0201
O/C
FOR OFFICE USE ONLY.
Oilfield Site Restoration Fee Return
Oil and Condensate Production
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
1a. Full rate
x
.015.......... 1b
●
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 (1.25% per month from due date to date of payment) 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 last day of the 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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