Form R-20128 - Request For Waiver Of Penalties For Delinquency And/or Underpayment

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R-20128 (3/06)

Request for Waiver of Penalties for

Delinquency and/or Underpayment

Louisiana Department of Revenue

P.O. Box 201

Baton Rouge, LA 70821-0201

Please Print or Type.

Taxpayer

Account Number

Tax

Period(s)

Type of Penalty

❏

Delinquent

Late Payment

UET

Other

I hereby assert that the delinquency in filing the subject return and/or paying the subject tax was not due to my intent to

violate the law, but was due to the following reason(s):

Pursuant to the provisions of Louisiana Revised Statute 47:1603 and based on the causes described in the preceding

paragraph, request is hereby made that the penalties of $____________________ incurred under the provisions of R.S.

47:1602 and, or 47:118 be waived.

Under the penalty of perjury, I declare all of the facts alleged above as a basis for reasonable cause, to the best of my knowledge and belief, including all

accompanying documentation, are true, correct, and complete.

Date

Signature

Official Title (if acting for a corporation)