State of Louisiana
R-19025 (9/02)
Department of Revenue
Installment Request for Individual Income
This agreement cannot exceed six (6) months.
Note: Do not file this form if you are currently making payments on an installment agreement.
During the existence of this agreement, you must file all state tax returns and pay all state taxes timely.
Monthly installments are available to taxpayers who are unable to pay the full balance owed by the due date. During this period,
you must submit monthly payments equal to the amount of the installment payment being requested on the reverse side of
this form.
To apply for an installment agreement, complete the front and back of this form and attach it to the front of the IT-540 return.
20% of the total amount of tax owed must be remitted with the return and this request. If this request is being made in
response to a notice, mail this form, the coupon found at the bottom of the notice, and the down payment.
For more information about an installment request, contact the Collection Division at (225) 219-7448 or P. O. Box 201,
Baton Rouge, LA 70821-0201.
A Notice of State Tax Lien may be filed to protect the State’s interest until you pay in full.
Please print or type.
Your first name and middle initial
Last name
Social Security Number
Spouse’s first name and middle initial
Last name
Social Security Number
Your current address (number and street)
Apartment number
City, State, ZIP
Has your address changed since you filed your last return? ❑ yes
❑ no
Your daytime telephone number
Best time to call
Name of your bank or other financial institution
Address of your bank or other financial institution
City, State, ZIP
Your employer
Your work telephone number
Your employer’s address
City, State, ZIP
Spouse’s employer
Your spouse’s work telephone number
Spouse’s employer’s address
City, State, ZIP
What is the tax year(s) for which you are making this request?
What is the total amount you owe on your tax return(s)?
This agreement cannot exceed six months. To limit higher penalty and interest charges, submit the maximum amount
possible. Penalty and interest charges will continue to accrue until the balance is paid in full.
Your signature
Spouse’s signature
Date
6333