Form R-5328 - Gasoline Tax Refund Registration For Farmers

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R-5328 (07/07)
GASOLINE TAX REFUND REGISTRATION
FOR FARMERS
• This form must be completed and submitted to
Louisiana Department of Revenue
the Department of Revenue before the applicant
Taxpayer Services Division/Excise Taxes Section
may purchase gasoline for which a refund claim
P. O. Box 201
will be fi led.
Baton Rouge, LA 70821-0201
• A copy of your latest federal income tax return
(225) 219-7656
(225) 219-2114 (TDD)
must accompany this application.
Please Print or Type
Name of Applicant
Date (MM,DD,YYYY)
Physical Address
Mailing Address
City
State
Zip
LA Account ID
FEIN/SSN
Home Telephone Number
Offi ce Telephone Number
Fax Number
Location of farm
Parish
Total number of acres cultivated
Other status:
Is farm owned by applicant?
Is farm leased?
_ Yes
_ No
_ Yes
_ No
If more than one farm is by applicant, the above information for each additional farm must be furnished on the reverse.
List tractors and farm machinery in which refund gasoline will be used to operate or propel the equipment used
in tilling the soil and for production of crops. If space is insuffi cient, attach a schedule.
Kind of Machine
Make
Model
Equipment ID Number
(If space is insufficient, attach schedule)
Signature of applicant
X
Furnish signatures of any other persons authorized to sign refund invoices for the above applicant when fuel is purchased.
Signature
Signature
X
X
FOR OFFICE USE ONLY
Region
Verifi ed By
Date (MM,DD,YYYY)

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