Form R-16017 - Non-Resident Contractor'S Application For Louisiana Revenue Account Number

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R-16017 (11/08)
Non-Resident Contractor’s Application for
Louisiana Revenue Account Number
Taxpayer Services Division
P.O. Box 4998
Baton Rouge, LA 70821-4998
(225) 219-7356, Option 3
PLEASE PRINT OR TYPE.
Date of application
(mm/dd/yyyy) _____________________
1
Sales/Use
Withholding
Non-employee Compensation
Other
■
■
■
■
Indicate the account number you use for each tax filed with the Louisiana Department of Revenue.
2
LA Corp. Tax Number
None
LA Sales Tax Number
None
LA Withholding Tax Number
None
■
■
■
Legal name(s)
3
Trade name of business
Telephone
Business location address
(NO P.O. Box or General Delivery)
4
City
State
ZIP
Mailing Address for receiving tax forms and correspondence
(If same as business location, write “same”.)
5
City
State
ZIP
Telephone
6
Type of organization:
Individual
Partnership
Corporation
Other ____________________________________
■
■
■
■
7
U.S. NAICS Code
required 
(see instructions)
8
Federal Employer ID Number
None
■
If sole owner
: Name
(individual)
SSN
Home address
9
Telephone (
City
State
ZIP
Name
Title
SSN
If corporation
Address
City
State
ZIP
or partnership:
Telephone (
name, title,
Social Security
Name
Title
SSN
Number, home
10
address, and
Address
City
State
ZIP
Telephone (
telephone
number of
Name
Title
SSN
each officer or
partner
Address
City
State
ZIP
Telephone (
Louisiana Secretary of State Charter Number
State of incorporation
(if known)
(if not Louisiana)
11
Mo. Day
Yr.
Domestic
Foreign
Fiscal Month
12 Corporation Income/Franchise: Date charter filed with Louisiana Secretary of State
13 Sales or Use Tax: Date business begin operations in Louisiana
14 Withholding Tax:
Select filing frequency.
(See instructions.)
■
quarterly
■
monthly
■
semi-monthly
Description of business or work performed
(required) (See instructions.):
15
I affirm that the information given on this application is true and correct.
Applicant Name
Applicant Title
(Please print.)
Applicant Signature
Date
(mm/dd/yyyy)
X
Preparer Name
Preparer Title
(Please print.)
Preparer Signature
Date
(mm/dd/yyyy)
X

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