Form R-9100 - Oil Severance Tax Electronic Filing Payment Voucher
Download a blank fillable Form R-9100 - Oil Severance Tax Electronic Filing Payment Voucher in PDF format just by clicking the "DOWNLOAD PDF" button.
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Complete Form R-9100 - Oil Severance Tax Electronic Filing Payment Voucher with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
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1 R-9100 (11/10)
Oil Severance Tax Electronic
Filing Payment Voucher
Louisiana Department of Revenue
Severance Tax Division
P.O. Box 3138
Baton Rouge, LA 70821-3138
Important notice
The coupon below must be used as a remittance advice by those oil severance tax filers who have submitted their oil severance tax
returns through on-line electronic filing, and who are not required or who have not elected to submit their remittances through electronic
funds transfer. In order to avoid the assessment of penalties and interest, remittance of the full amount due on the electronically filed
return must be submitted to the Department on or before the 25th day of the second month following the taxable period. Please assure
that your oil severance tax account number and the filing period are correctly shown in the spaces provided on the coupon. Please
complete and retain the top portion of this form as a record of your payment.
{Complete and retain this portion as a record of payment.}
PLEASE PRINT OR TYPE.
Name
Account number
Address
Filing period (MM/YY)
City
State
ZIP
DO NOT SEND CASH.
Amount of payment
Check number
Date sent
Detach and submit the voucher below with your payment.
Oil Severance Tax Electronic Filing Payment Voucher
R-9100 (1/07)
Name
Account number
O
Address
Filing period (MM/YY)
City
State
ZIP
Make payment to
AMOUNT
u
DO NOT SEND CASH.
ENCLOSED
Louisiana Department of Revenue
P.O. Box 3138
Baton Rouge, LA 70821-3138
FOR OFFICE USE ONLY.
Mail date
1903
19034
4358485649
113
12312006 00000000 4376538544
00000500009 9
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