Form R-1021 - Sales Tax Electronic Filing Payment Voucher - Louisiana Department Of Revenue - 2005

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R-1021 (1/05)
Louisiana Department of Revenue
Sales Tax Division
P.O. Box 3138
Baton Rouge, LA 70821-3138
Sales Tax Electronic Filing Payment Voucher
Important notice
The coupon below must be used as a remittance advice by those sales tax filers who have submitted their sales tax returns
through on-line electronic filing, and who are not required or who have not elected to submit their remittances through electronic
funds transfer. In order to avoid the assessment of penalties and interest, remittance of the full amount due on the electronically
filed return must be submitted to the Department on or before the 20 th day of the month following the close of the calendar
month covered by the return. Please assure that your sales tax account number and the filing period are correctly shown in
the spaces provided on the coupon. Please complete and retain the top portion of this form as a record of your payment.
Do not send cash.
Complete and retain this portion as a record of payment.
Sales Tax Electronic Filing Payment Voucher
Name __________________________________________
Account number ________________________________
Address ________________________________________
Filing period (Month/Year) __________________________
City, State, ZIP __________________________________
Amount of payment ____________________________
Check number__________________________________
Date sent ______________________________________
Detach and submit the voucher below with your payment by the 20 th of the month following the month of the return.
Sales Tax Electronic Filing Payment Voucher
R-1021 (1/05)
S
Name__________________________________________
Address ________________________________________
Account number __________________________________
City, State, ZIP __________________________________
Filing period (month/year) __________________________
AMOUNT
Make payment to:
ENCLOSED
•
Louisiana Department of Revenue
P.O. Box 3138
4003
Baton Rouge, LA 70821-3138
Mail date
Do not send cash.
For office use only.
4 0 0 3 0
4 4 3

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