Form R-5197 - Quarterly Report Of Inspection And Supervision Fee
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1Batch type = 763 or 4
R-5197 (01/06)
Quarterly Report of Inspection
and Supervision Fee
Taxpayer Services Division
Excise Taxes Section
P. O. Box 201
Baton Rouge, LA 70821-0201
(225) 219-7656
(225) 219-2114 (TDD Number)
For office use only
Quarter ending
Certificate and/or Permit Number
To avoid penalties, return must be transmitted on or before due date stated on reverse side of this form, or
ISF
the next business day after the due date, if the due date falls on a holiday or weekend.
1.
$
Line 1. Total Intrastate gross receipts for the calendar year (Jan. 1 to current period ending date) ..........
2.
$
Line 2. BASIC FEE (Enter amount computed from schedule on reverse side.)..........................................
Line 3. SUPPLEMENTAL FEE (Act 561 of the 1985 Regular Legislative Session imposes a supplemental
fee on all gas, electric, and telephone public utilities.)
3A. $
3A. Total gas, electric, and telephone receipts included in Line 1 ......
%
3B. $
3B. Ratio: (Line 3A ÷ Line 1) x 100 = % rate ......................................
3C. $
3C. Fee (Enter amount shown on Line 2.) ..........................................
3D. Portion of Line 2 applicable to Supplemental Fee
3D. $
(Line 3B x Line 3C) ........................................................................
3E. SUPPLEMENTAL FEE: Line 3D x 20% ....................................................................................
3E. $
Line 4. TOTAL FEE (Line 2 + Line 3E)..........................................................................................................
4.
$
5.
$
Line 5. Less: Line 4 of prior quarter's return (See instructions.) ..................................................................
Line 6. NET FEE DUE (Line 4 less Line 5) ..................................................................................................
6.
$
Line 7. Penalty, if report is delinquent
(5% for each 30 days or fraction thereof not to exceed 25%) ........................................ PENALTY
7.
$
Line 8. Interest, if report is delinquent
(See instructions.) .......................................................................................................... INTEREST
8.
$
Line 9. Enter amount of fee, penalty, and interest.
........................................ PAY THIS AMOUNT.
(Make payment to Department of Revenue. Do not send cash.)
9.
$
AFFIDAVIT
Under the penalties of perjury, I declare that I have examined this report, including all accompanying documents, and to the best of my
knowledge and belief, it is true, correct, and complete.
Sworn to and subscribed before me this
Signature of preparer
______day of______________________ ,
________
Year
Title
(
)
Telephone
Signature of officer
Title
7600
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