Bank Draft Information And Application Form For Participation In The Automatic Bank Draft Program


Bank Draft Information
Taxpayers electing to have monthly installment payments debited from their account by bank draft are required to
complete the application below. The following information must be included on the application:
(a) The routing number is the first nine digits listed on the lower left hand side of your check.
(b) The account number is the second group of numbers after the routing number. Do not include the check number.
(c) The start date is the date of the first draft.
(d) The date of debit is the date you indicate when you would like your account to be debited.
(e) The debit amount is the payment amount authorized by the taxpayer.
(f) The tax period(s) list the periods outstanding.
(g) The amount due is the balance due from all periods listed.
(h) The number of payments will be the number of drafts on this account.
Bank account name is the name listed at the bank or financial institution (ex: Mr. and Mrs. John Smith, John or
Jane Smith, Smith’s Car Care, if a business)
Checking or Savings is the type of bank account being debited.
(k) Enter your social security number and your spouse’s social security number (if applicable).
(l) LDR account number is the ten-digit business account number assigned to you by LDR.
Installment payments will be debited from your account on the date you specify. Failure to have sufficient funds in
your account at the time of the debit will result in a NSF fee being added to the balance due and may result in your
agreement being cancelled. If the agreement is cancelled, all tax, penalties, and interest will be immediately
When the payment plan request has been approved, you will be notified of the effective date.
Requests for voluntary participation must be directed to: Louisiana Department of Revenue
Collection Division
Post Office Box 66658
Baton Rouge, Louisiana 70896-6658
Application for Participation in the Automatic Bank Draft Program
Bank Routing Number: __________________________Bank Account Number: ____________________________
Start Date: ________________
Debit Date:_________________
Debit Amount: $ ____________
Tax Period (s): _______________________ Amount Due:$__________________Number of Payments______
Bank Account Name: __________________________________
Taxpayer’s Social Security Number: ________________Spouse’s Social Security Number: ____________________
LDR Business Account Number (if applicable): ____________________
Signature and Verification
Under penalties of perjury, I (we) declare that the information is to the best of my (our) knowledge and belief is true,
correct, and complete. I agree to participate in this Automatic Bank Draft Program.
I also authorize the financial institutions involved in processing the electronic payment of taxes to receive confidential
information necessary to answer inquiries and resolve issues related to the payment.
Your signature
Spouse’s signature
617 North Third Street
P. O. Box 201
Baton Rouge, Louisiana 70821-0201
225-219-7448 225-219-2256 Fax
TDD# 225-219-2114


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