Form R-20083 - Louisiana Tax Amnesty Application - State Of Louisiana Page 2

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Louisiana Tax Amnesty Application
Individual
Taxpayer name _________________________________
Social Security Number __________________________
Spouse name __________________________________
Social Security Number __________________________
Address _______________________________________
City, State, ZIP _________________________________
(
)
Telephone number ______________________________
Business
Owner/corporate name ___________________________
Social Security Number __________________________
Business name _________________________________
Business fiscal year ends _________________________
Mailing address _________________________________
City, State, ZIP _________________________________
(
)
Telephone number ______________________________
Are you currently registered with the Department of Revenue?
Yes
No
If yes, please indicate your state tax registration number. __________________________________________________
If no, please indicate the type of business you operate. ___________________________________________________
Federal Taxpayer Identification Number ________________________________________________________________
Please specify the taxes and tax periods for which you are applying for amnesty. If applicable, also include the date your
business began operating for the tax indicated, and the date your business ceased to operate for the type of tax indicated.
Only the taxes and periods indicated on this application can be considered.
Type of Tax
Tax Periods Included
Individual Income
____________________________________________
Gift
____________________________________________
Inheritance and Estate Transfer
____________________________________________
Fiduciary
____________________________________________
Sales/Use
____________________________________________
Corporation Income
____________________________________________
Corporation Franchise
____________________________________________
Income Tax Withholding
____________________________________________
Other (Please specify.) ___________________
____________________________________________
Are your tax returns attached to this application?
Yes
No
Assistance
If you have any questions about the amnesty program, or if you need additional amnesty applications, please call the
Amnesty Hotline or any office listed below.
Amnesty Hotline 1-800-662-0546
Alexandria
900 Murray Street, Room B-100
(318) 487-5333
Baton Rouge
8490 Picardy Avenue, Building 600
(225) 763-5700
Baton Rouge, Main Office
330 North Ardenwood
(225) 925-7456
Lafayette
825 Kaliste Saloom Road, Brandywine III, Suite 150
(318) 262-5455
Lake Charles
One Lakeshore Drive, Suite 1550
(318) 491-2504
Monroe
122 St. John Street, Room 105
(318) 362-3151
New Orleans
1555 Poydras Street, Suite 900
(504) 568-5233
Shreveport
1525 Fairfield Avenue
(318) 676-7505
Thibodaux
1418 Tiger Drive
(504) 447-0976
Houston
5177 Richmond Avenue, Suite 325
(713) 629-8335
Dallas
4100 Spring Valley Road, Suite 315-LB #15
(972) 701-9682
Please mail application, returns, and payment to:
Louisiana Department of Revenue
P. O. Box 144
Baton Rouge, LA 70821-0144

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