Form R-1341a - Contract Completion Form - 2002 Page 2

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State Income Tax Withholding
17.
Gross payroll $ _____________________________
Louisiana tax withheld $ ________________________
If no Louisiana tax withheld, please explain. ______________________________________________________
17a.
State income tax withheld
Period
__________________________________________________
(beginning month/year through ending month/year)
Account number (10-digit number) _____________________________________________________________
Corporation Income Franchise/Individual Income Tax
18.
Corporation franchise tax account number _______________________________________________________
18a.
Estimated franchise taxable base ______________________________________________________________
18b.
Income tax account number
________________________________________________________
(if corporation)
18c.
Social Security Number
_____________________________________________________________
(if individual)
18d.
Account name _____________________________________________________________________________
18e.
Estimated tax payments _____________________________________________________________________
18f.
Estimated net income from contract ____________________________________________________________
Unemployment Insurance Tax
19.
Louisiana unemployment insurance account number _______________________________________________
19a.
Federal Identification Number _________________________________________________________________
The undersigned certifies that the above is a complete and accurate statement of liabilities incurred and payments made for
the Louisiana state and local taxes indicated, pursuant to the contract identified above.
____________________________________________________________
_______________________________
Authorized signature
Date
____________________________________________________________
_______________________________
Notary public
Date

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