Form Sev. M-1s - Severance Tax For Minterals - Louisiana Department Of Revenue - 1997 Page 2

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Reporting company name
Reporting company number
Minerals
Reporting company address (Including ZIP code)
Report submitted during month of
Page _________ of ________
Schedule A
All resources severed and/or purchased on which severance tax is being paid herewith (Minerals other than petroleum resources)
Column 1
Column 2
Column 3
Column 4 Column 5
Column 6
Column 7
Column 8
Column 9
Column 10
Taxable
Penalty and
period
Name and address of
Resources
Resource
Name of pit lease or
Parish
Quantity severed
Tax due
interest
Total amount due
severer or purchaser
severed
code no.
mine and location
Mo.
Yr.
code no.
Tax rate
or purchased
(Round to nearest dollar.)
(Round to nearest dollar.)
(Round to nearest dollar.)
$
00 $
00 $
00
$
00 $
00 $
00
$
00 $
00 $
00
$
00 $
00 $
00
$
00 $
00 $
00
$
00 $
00 $
00
$
00 $
00 $
00
Schedule B
List all resources severed and/or purchased on which others are to pay severance tax.
Taxable
Parish
period
Resources
Resource
code
severed
code no.
Mo.
Yr.
Quantity severed
Quantity purchased
Name of taxpayer
Address of taxpayer
no.

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