Form R-1340 - Certification Of Resident/nonresident Status By Contractors And Subcontractors Working In The State

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R-1340 (6/09)
New
■
Certification of Resident/Nonresident Status by
Contractors and Subcontractors Working in the State
Renewal
■
La. RS 47:9
Mail or fax completed application to:
Louisiana Department of Revenue
Taxpayer Services Division
P.O. Box 4998
Baton Rouge, LA 70821-4998
Phone: (225) 219-7356 • Fax:(225) 219-2065
PLEASE PRINT OR TYPE.
Legal Name
Trade Name
(if any)
Mailing Address
City
State
ZIP
Daytime Telephone
Email
If you are currently registered with the Louisiana Department of Revenue for the following taxes, please list your 10-digit account numbers.
Sales Tax
Withholding Tax
Corporation Income/Franchise Tax
Type of Organization
■
Partnership
■
Corporation
Date of incorporation
(mm/dd/yyyy) _______________________
■
Individual
_________________________
Social Security Number
■
Other
______________________________________________________________________________
Please specify.
1
Have you been actively engaged at any time since July 6, 1984, in performing work on contracts in Louisiana?
■
■
Yes
No
■
If you acknowledge that you are a nonresident contractor or subcontractor who is subject to the contract
registration and bonding requirements of R.S. 47:9 et al., please mark this box.
If you marked the box acknowledging you are a non-resident contractor or subcontractor subject to the
requirements of La. R.S. 47:9 et.al., skip to the authorization box to sign and date the questionnaire.
If you claim not to be subject to the contract registration and bonding requirements of La. R.S. 47:9, you must
answer questions 1-6.
Have the owners of this business been permanent residents of Louisiana for at least one year prior
2
■
■
Yes
No
to bidding on work in Louisiana?
If “yes”, please list the Louisiana location address of each owner that has been his permanent residence
for the past year. If any owners have had more than one permanent address in the past year, please list all
of them, including the dates of change. Do not list post office boxes. List names, addresses, and social
security numbers for all members of LLCs, Partnerships, or LTDs.
Owner Name
Address
City
State
ZIP
SSN*
* Social Security Number
Questionnaire continued on reverse side.

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