Form R-1022 - Application For Offshore Registration Number

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R-1022 (12/16)

Mail completed form to:

Application for

Department of Revenue

Offshore Registration Number

Revenue Processing Center

P. O. Box 4998

Baton Rouge, LA 70821-4998

Revised Statute 47:305.10

Phone: (855) 307-3893

Please mark appropriate box.

New Application

Renewal

PLEASE PRINT OR TYPE.

Part 1

Legal Name

Louisiana Sales Tax Account No.

Trade Name

Telephone

Location Address of Storage of Tax-free Property

City

State

ZIP

Mailing Address of Principle Office

City

State

ZIP

Part 2

Please provide a detailed description of all business activities.

Please provide a description of business conducted in the offshore area.

Part 3

Is tangible personal property used or consumed in the offshore area beyond the territorial limits of Louisiana or any state on a regular basis during the

normal course of business?

Yes

(If you answered no to this question, go directly to Part 4.)

If yes, list the type of property normally used or consumed beyond the offshore boundary.

Part 4

Are accounting records maintained that will accurately record and identify the actual location of ultimate use of all property that is to be purchased tax free under the

provisions of Louisiana Revised Statute 47:305.10(C)(2)?

Yes

Briefly describe the accounting system used to control inventories.

Where are those records kept?

Under penalty of perjury, I declare that I have examined this application for exemption and accompanying documents, and to the best of

my knowledge and belief it is true, correct, and complete.

Print/Type Name

Title

Signature of Applicant

Date

(mm/dd/yyyy)