R-9000-L (11/97)
State of Louisiana
FORM SEV. M-1s
Department of Revenue
Page _________ of ________
Severance Tax – MINERALS (Other than petroleum products)
P. O. Box 201, Baton Rouge, Louisiana 70821-0201
File original of this return only.
Reporting company name
Reporting company number
This report must be complete in all
Parish Summary – Minerals
respects, showing parish or par-
ishes from which these resources
Tax Paid Herewith
Reporting company address (including ZIP code)
Report submitted during month of
were severed and tax on same,
including the information requested
This report is due on or before the last day of the month following the taxable month and becomes delinquent on the first day
Certification
in schedules on the reverse side of
thereafter. If the due date falls on a weekend or holiday, the return is due the next business day and becomes delinquent the
this report.
Under the penalties of perjury, I declare that I have examined this return, including all accompanying documents, and to the
first day thereafter.
best of my knowledge and belief, it is true, correct, and complete.
Parish Summary – Tax Paid Herewith
I understand that the information reported on this return will be used in the administration and enforcement of the Severance
Tax laws, rules and regulations, and may be disclosed to other parties involved in these reported transactions.
Taxable
Penalty and
Quantity
Tax due
Total amount due
period
interest
Name and Title (Print or type.) _____________________________________________________________________________
Parish
Product
Parish name
(tons)
(Round to nearest dollar.)
(Round to nearest dollar.)
Mo. Yr.
(Round to nearest dollar.)
code
code
____________________________________________________________________
$
.00 $
.00 $
.00
Signature
Date
(
)
$
.00 $
.00 $
.00
Telephone _____________________________________________________________________________________________
Summary - Resources Tax Due
(To be completed only on last page of SEV. M-1s.)
$
.00 $
.00 $
.00
Resource
Resource
Net quantity
Tax due amount
$
.00 $
.00 $
.00
code number
severed
severed by tons
Tax rate
(Round to nearest dollar.)
21
Sulphur
$1.03/long ton $
.00
$
.00 $
.00 $
.00
22
Salt
.06/ton
$
.00
$
.00 $
.00 $
.00
23
Salt Brine
.005/ton
$
.00
$
.00 $
.00 $
.00
26
Sand-washed
.06/ton
$
.00
$
.00 $
.00 $
.00
27
Sand-river
.06/ton
$
.00
$
.00 $
.00 $
.00
28
Sand-other
.06/ton
$
.00
$
.00 $
.00 $
.00
Shell-reef
29
.06/ton
$
.00
$
.00 $
.00 $
.00
or oyster
30
Shell-clam
.06/ton
$
.00
$
.00 $
.00 $
.00
31
Stone crushed
.03/ton
$
.00
$
.00 $
.00 $
.00
32
Marble
.20/ton
$
.00
$
.00 $
.00 $
.00
33
Lignite
.12/ton
$
.00
$
.00 $
.00 $
.00
$
.00 $
.00 $
.00
Make payment to:
Total tax due
$
.00
Louisiana Department of Revenue
$
.00 $
.00 $
.00
Penalty and interest
$
.00
Do not send cash.
$
.00 $
.00 $
.00
Total amount due
$
.00
$
.00 $
.00 $
.00
$
.00 $
.00 $
.00
$
.00 $
.00 $
.00