Form Sev 0-3 - Monthly Incapable And Stripper Oil Well Report

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0-3

FORM SEV

Oil Severance Tax

R-9003 (7/06)

Page ________ of ________

File original of this return only.

MONTHLY INCAPABLE AND STRIPPER OIL WELL REPORT

Louisiana Department of Revenue

P.O. Box 201

Baton Rouge, LA 70821-0201

PLEASE PRINT OR TYPE.

Reporting company name

Revenue Account Number

Reporting company address (including ZIP code)

Reporting Company Number

Taxable Period

No.

Conservation codes

Field name

Cont.

Cert.

Conservation

Parish

Average

Disposition

Taxpayer

Production

Producer name

status

(barrels)

prod

code

well serial no.

code

Field

Producer

Lease

Well no.

daily prod.

(barrels)

number

Lease and well name

code

days

This report is due on or before the twenty-fifth 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.