Form R-9050 - Oilfield Restoration Fee Return Oil And Condensate Production
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R-9050 (5/10)
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Account Number:
Oilfield Restoration Fee Return Oil
Name (1):
and Condensate Production
Name (2):
Louisiana Department of Revenue
P.O. Box 201
Address (1):
Baton Rouge, LA 70821-0201
(225) 219-7656 (225) 219-2114 (TDD)
Address (2):
City, State ZIP:
FOR OFFICE USE ONLY.
F i e l d f l a g
Filing Period (mm/yy)
O/C
Fee rate
Amount of fee
Barrels
Category
per barrel
(Round to the nearest dollar)
x
1 Full rate
1a
.015
1b
00
x
00
2 Incapable rate
2a
.0075
2b
x
00
3 Stripper rate
3a
.00375
3b
00
4 Total fees (Add Lines 1b, 2b, 3b.)
4
00
5 Interest (See instructions.)
5
00
6 Delinquent penalty (5% for each 30 days or fraction thereof, not to exceed 25% of Line 4) 6
Total fees, interest, and penalty due
00
7
☛ ☛
7
Pay this amount
.
Make payment to: Louisiana Department of Revenue. DO NOT SEND CASH.
This return is due on or before the 25th day of the second month following the taxable period and becomes delinquent on the first day
thereafter. If the due date falls on a weekend or legal holiday, the return is due the next business day and becomes delinquent the first
day thereafter.
PLEASE PRINT OR TYPE.
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. If a person other than the taxpayer prepares the return, this declaration is based on all the information relating
to the matters required to be reported of which the preparer has knowledge.
Date (mm/dd/yyyy)
Signature
Title
Telephone Number Number
X X
Date (mm/dd/yyyy)
Signature of preparer other than taxpayer
Preparer ID
Telephone Number
X X
Complete only if change in business status has occurred.
Date business discontinued (mm/dd/yyyy)
Date business sold (mm/dd/yyyy)
Name of purchaser
5500
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