Form R-20128 - Request For Waiver Of Penalties For Delinquency - 1995
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1State of Louisiana
R-20128 (1/95)
Department of Revenue and Taxation
P.O. Box 201
Baton Rouge, LA 70821-0201
REQUEST FOR WAIVER OF PENALTIES FOR DELINQUENCY
Requested waiver:
$ ________________________________________________________
Taxpayer:
_________________________________________________________
Account number:
_________________________________________________________
Tax:
_________________________________________________________
Period(s):
_________________________________________________________
I hereby assert that the delinquency in filing the subject return or paying the subject tax was not due to my intent to
violate the law, but was due to the following reason(s):
Pursuant to the provisions of Louisiana Revised Statute 47:1603 and based on the causes described in the preceding
paragraph, request is hereby made that the penalties of $__________________________ incurred under the provi-
sions of R.S. 47:1602 be waived.
Signature:
_________________________________________________________
Title:
_________________________________________________________
Date:
_________________________________________________________
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