Form R-9011l - Severance Tax-Minerals (Other Than Petroleum Products)

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R-9011L(1/06)
Page_______ of _______
M–1A/B
FORM SEV.
SEVERANCE TAX–MINERALS (other than petroleum products)
Louisiana Department of Revenue
P.O. Box 201, Baton Rouge, LA 70821-0201
▼
▼
FILE ORGINAL OF THIS RETURN ONLY.
Reporting company name
Revenue Account Number
▼
▼
Reporting company address (Including ZIP Code)
Taxable Period
Address
State
ZIP
SCHEDULE A
All resources severed and/or purchased on which severance tax is being paid with this form.
Quantity
Name and Address of
Resources
Resource
Name of Pit Lease or
Parish Code
Penalty and
Severed or
Tax Rate
Tax Due
Total Amount Due
Severer or Purchaser
Severed
Code NO.
Mine and Location
NO.
Interest
Purchased
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
SCHEDULE B
List all resources severed and/or purchased on which others are to pay severance tax.
Parish
Resources
Resource Code
Code
Quantity Severed Quantity Purchased
Name of Taxpayer
Address of Taxpayer
Severed
NO.
NO.

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