Form M - 1 A/b - Severance Tax-Minerals (Other Than Petroleum Products) - State Of Louisiana Department Of Revenue

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State of Louisiana
R-9011 – L(2/04)
Department of Revenue
M – 1 A/B
FORM SEV.
Page_______ of _______
P.O. Box 201, Baton Rouge, LA 70821-0201
SEVERANCE TAX–MINERALS (OTHER THAN PETROLEUM PRODUCTS)
Reporting company name
Revenue Account Number
Reporting company address (Including ZIP Code)
Taxable Period
FILE ORGINAL OF THIS RETURN ONLY.
Schedule A
All resources severed and/or purchased on which severance tax is being paid with this form.
Name and Address of
Resources
Resource
Name of Pit Lease or
Parish Code
Quantity Severed
Penalty and
Tax Rate
Tax Due
Total Amount Due
Severer or Purchaser
Severed
Code NO.
Mine and Location
NO.
or Purchased
Interest
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Schedule B
List all resources severed and/or purchased on which others are to pay severance tax.
Parish
Resources
Resource Code
Code
Severed
NO.
Quantity Severed
Quantity Purchased
Name of Taxpayer
Address of Taxpayer
NO.

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