Form R-9003-L - Monthly Incapable And Stripper Oil Well Report

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Page ________ of ________

State of Louisiana

R-9003-L (12/03)

File original of this return only.

Department of Revenue

0-3

FORM SEV

P.O. Box 201

Oil Severance Tax

Baton Rouge, LA 70821-0201

Monthly Incapable and Stripper Oil Well Report

Reporting company name

Revenue Account Number

Reporting company address (including ZIP code)

Reporting Company Number

Taxable Period

Conservation codes

No.

Field name

Conservation

Cert.

Parish

Production

Average

Disposition

Taxpayer

Cont.

Producer name

code

well serial no.

code

prod.

daily prod.

status

(barrels)

number

Lease and well name

Field

Producer

Lease

Well no.

days

code

This report is due on or before the fifteenth 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 holiday, the

return is due on the next business day and becomes delinquent on the first day thereafter.