Form R-16019 - Application For Louisiana Revenue Account Number

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R-16019 (6/05) CR1
Application for Louisiana Revenue Account Number
P.O. Box 201
For office use only.
Baton Rouge, LA 70821-0201
(225) 219-7318
Date of application
A. Sales/ Use
B.
Withholding
F.
Other
1.
General Business
C.
Vehicle Rental Excise
__________________
Statewide Hotel/Motel
D.
Severance
Jefferson Parish Hotel/Motel
E. Oil and Gas Classification
Orleans Parish Hotel/Motel
Taxpayer Only
Orleans Parish Restaurant
Producer Only
N.O. Airport Food Establishments
Producer/Taxpayer
2.
Reason for applying
A.
Started new business
C.
Other (specify)
B.
Purchased ongoing business: Name of previous owner
3.
Indicate the account number you use for each tax filed with the Louisiana Department of Revenue.
LA Corp. Tax Number
None
LA Sales Tax Number
None
LA Excise Taxes Number
None
LA Withholding Tax Number None
LA Severance Tax Number
None
LA Natural Resource Number None
4.
A.
Legal name(s)
B.
Trade name of business
Telephone
5.
A.
Business location address
(NO P.O. Box or General Delivery)
B.
City and state
C. ZIP
6.
A.
Address for receiving tax forms and correspondence
(If same location, write “same”.)
Additional mailing
B.
C.
D.
E.
address(es) attached
City and state
ZIP
Telephone
7.
Type of organization:
A.
Individual
B.
Partnership
C.
Corporation
D.
Governmental
E.
Nonprofit
F.
Other
8.
U.S. NAICS Code
9.
Federal Employer
None
(required)
ID Number
10. If sole owner (individual): Name
SSN
Home address
Telephone
11. If corporation or
Name
Title
SSN
partnership: name,
Address
title, Social Security
(
)
Telephone _______________
Number, home
Name
Title
address, and
SSN
Address
telephone number
(
)
of officers or partners
Telephone _______________
12. A.
Louisiana Charter Number (if known) ____________________
B. State of incorporation (if not Louisiana) _____________
13. Permits -Sellers of liquor, beer, or wine (wholesale or retail), must obtain a permit from the Office of Alcohol and Tobacco Control.
A permit from the Louisiana State Police Gaming Division must be obtained by sellers of lottery tickets or operators of video poker
games. Indicate permit number(s) that you currently hold.
A.
Lottery Permit Number
B.
Expiration Month/Year ________________________
Alcohol Permit Number
Expiration Month/Year ________________________
VPG Permit Number
Expiration Month/Year ________________________
Mo. Day
Yr.
Domestic
Foreign
Fiscal Month
14. A. Corporation Income/Franchise: Date charter filed with Louisiana Secretary of State
B.
C.
15. Sales or Use Tax: Date business begins operation from this location
❑ quarterly ❑ monthly ❑ semi-monthly
16. Withholding Tax:
Select filing frequency.
(See instructions.)
❑ quarterly ❑ monthly ❑ 45-day
17. Severance Tax: Select filing frequency.
18. Description of business:
I affirm that the information
Signature of applicant
Title
______________________________________________________________________________
given on this application is true
Signature of preparer
Date
______________________________________________________________________________
and correct.
1500

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