Form R-9010 - Certification Of Continued Responsibility For Payment Of Oil Spill Contingency Fee

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R-9010 (5/91)
State of Louisiana
Department of Revenue and Taxation
Severance Tax Division
Post Office Box 201
Baton Rouge, LA 70821-0201
Certification of Continued Responsibility for Payment of
Oil Spill Contingency Fee
R.S. 30:2451–2496
This certifies that _____________________________________________________________________
name
__________________________________________________________________________________
address
is registered with the Louisiana Department of Revenue and Taxation as a marine terminal operator, account
number ______________________________, and agrees to remit to the Louisiana Department of Revenue
and Taxation the oil spill contingency fee on all oil subject to the fee which is picked up from or delivered to
__________________________________________________________________________________
name
__________________________________________________________________________________
address
By signing this certification, the terminal operator assumes responsibility for payment of the fee and becomes
the party to whom the Louisiana Department of Revenue and Taxation will look for payment. The terminal
operator accepting this certification should retain it in his records until all applicable periods have prescribed.
A copy must be furnished to the Louisiana Department of Revenue and Taxation.
_______________________________________
_______________________________________
_________________
Area code and telephone number
Signature
Date

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