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Louisiana

R-8453OL (1/17)

LA 8453OL

2016 Individual Income Tax Declaration for Electronic Filing

0 0

IRS DCN u

Your first name and initial

Last name

Your Social

Security

Number

Spouse’s first name and initial

Last name

Spouse’s

Social Security

2016

Number

Present home address (number and street including apartment number or rural route)

Daytime

Telephone

Number

City, town, or post office

State

ZIP

Part A

Tax Return Information

Balance Due

Refund due

Part B

Direct Deposit of Refund (Optional)

or Direct Debit (Optional)

■

Routing Number The first 2 digits of the routing

number must be 01 through 12 or 21 through 32.

Direct Debit Payment

Account Number

Withdrawal Date

Full Payment

■

Partial Payment

■

Type of Account:

Checking

Savings

(Check one.)

■

Payment made/will be made by credit card.

PART C

Declaration of Taxpayer

■

I consent that my refund be directly deposited as designated in Part B, and declare that the information shown in Part B is correct. If

I have filed a joint return, this is an irrevocable appointment of the other spouse as an agent to receive the refund.

■

I do not want direct deposit of my refund, am a first-time filer with Louisiana, or am not receiving a refund. I understand that by not

having my refund direct deposited I will receive my refund by paper check.

■

I authorize the Louisiana Department of Revenue and its designated Financial Agent to initiate an ACH electronic funds withdrawal

(direct debit) entry to the financial institution account indicated in Part B for payment of my State taxes owed on this return. I also

authorize the financial institutions involved in processing the electronic payment of taxes to receive confidential information neces-

sary to answer inquiries and resolve issues related to the payment.

I understand that if I have filed a balance due return and if the Louisiana Department of Revenue does not receive full and timely

payment of my tax liability, I will remain liable for the tax liability and all applicable interest and penalties.

I declare that I have examined my state income tax return prepared for electronic transmission to the State of Louisiana and, to

the best of my knowledge and belief, it is true and complete.

Please sign here. _____________________________

__________

____________________________

______________

Your signature

Date

Spouse’s signature (if joint return)

Date

Do Not Mail

You must retain this form along with the state copy of your supporting

W2s and 1099s for a minimum of 3 years. DO NOT MAIL.

8453 Ol Form - Louisiana Department Of Revenue - Individual Income Tax Declaration For Electronic Filling

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