R-6001 - Application For A Direct Deposit Of A Business Tax Refund Form
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1R-6001 (11/05)
Application for a Direct Deposit
of a Business Tax Refund
Legal Name:
Trade Name:
Business Address:
Daytime Telephone Number:
City, State, Zip:
City
State
ZIP+4
Name of your Financial Institution:
❒
❒
Type of Account: Checking
Savings
Bank Account Name:
Bank Account Number:
Bank Routing Number:
❒
Sales
Account Number:
Filing period(s) (month, year) to be direct deposited: ________________________________________________________________
List your last payment amount and filing period $_______________________ for __________________________ (month, year)
❒
Withholding
Account Number:
Filing period(s) (month, year) to be direct deposited: ________________________________________________________________
List your last payment amount and filing period $_______________________ for __________________________ (month, year)
❒
Corporation Income\ Franchise
Account Number:
Tax return(s) (calendar year(s) or fiscal year(s) month, year) to be direct deposited: ______________________________________
List your Louisiana net income before loss and filing period $__________________ for _______________(year ending, month/year)
❒
Other: ____________________________________
Account Number:
(See the list below for the other taxes that can be direct deposited.)
Filing period(s) (month, year) to be direct deposited: ________________________________________________________________
List the amount and form of payment for last filing period: $___________________ for ___________ (month, year) by __________
OTHER TAXES THAT CAN BE DIRECT DEPOSITED
Excise Taxes
Severance Taxes
Miscellaneous Taxes
Beer
Special Fuels Supplier
Gas
Automobile Rental Excise
New Orleans Hotel/Motel (4 column)
Gas Dealer
Special Fuels User
Minerals
IFTA
Statewide Hotel/Motel
Gas Jobber
Tobacco
Oil
New Orleans Exhibition Hall
Gas Refund
Special Fuels Refund
Timber
Under penalties of perjury, I (we) declare that the information is true, correct, and complete, to the best of my (our) knowledge.
I also authorize the Louisiana Department of Revenue to transfer my business tax refund for the taxable year referenced above to the
bank account stated above.
_________________________________________________________
________________
Signature of Taxpayer or Taxpayer’s Authorized Representative
Date
_________________________________________________________
Please Print or Type Name of Taxpayer or Taxpayer’s Authorized Representative
Request may be mailed or faxed to:
Louisiana Department of Revenue
Taxpayer Services Division
Post Office Box 66362
Baton Rouge, LA 70896-6362
Fax Number (225) 219-2065
For requests submitted by fax or by mail, include a copy of picture identification (e.g., Louisiana Driver’s License) of the person who
signs the form if different from the person who signed the tax returns. For additional information, please call the Taxpayer Services
Division at (225) 219-7318.
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