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Form R-20211 - Document Checklist For Offer To Compromise Based On Serious Doubt As To Collectibility Page 4

R-20211 (11/98)

To whom it may concern:

Pursuant to Section 604(2) of the Fair Credit Reporting Act, you are hereby authorized to release financial

information, data, records, etc., that you may have access to or that is in your possession as it pertains to

________________________________________________

Full name of taxpayer

_________________________________________________________________________________

Address of taxpayer

_________________________________________________________________________________

Social Security Number of taxpayer

or to

________________________________________________

Full name of company

_________________________________________________________________________________

Address of company

_________________________________________________________________________________

Taxpayer identification number

to the Louisiana Department of Revenue, _____________________________________________,

Attention: Person or department

_______________________________________, _______________________________________.

Address

Telephone

I understand that the above requested information is confidential and protected under Louisiana Revised

Statute 47:1508. I further understand that anyone unlawfully divulging or disclosing this information in

violation of R.S. 47:1508 shall be punished in accordance with the law. I have been informed of my rights

under R.S. 47:1508 and understand my rights under that statute. Notwithstanding, I hereby consent to the

divulgence and disclosure of this otherwise confidential information and waive all of the rights granted to

me under R.S. 47:1508.

________________________________________________

Taxpayer signature

Sworn to and subscribed before me this __________ day of __________________________________,

Date

Month

__________, at East Baton Rouge Parish, State of Louisiana.

Year

Witnesses

_______________________________________

Notary Public

Form R-20211 - Document Checklist For Offer To Compromise Based On Serious Doubt As To Collectibility Page 4