Form R-540v 03 - Individual Income Tax Electronic Filing Payment Voucher - 2004
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1State of Louisiana
R-540V 03
Department of Revenue
P.O. Box 201
Baton Rouge, LA 70821-0201
Individual Income Tax Electronic Filing Payment Voucher
Important notice
Tax preparers should provide this form to clients who file electronically if a payment is due with the return. Taxpayer clients
who owe additional Louisiana individual income tax for 2003 must complete the payment voucher at the bottom of this
page, detach and mail by May 17, 2004, in order to avoid the assessment of penalties and interest. The top portion of
this form should also be completed and retained by the taxpayer as a record of payment.
DO NOT SEND CASH.
Complete and retain this portion as a record of payment.
Individual Income Tax Electronic Filing Payment Voucher
You can also make payments via the internet.
Go to
Name __________________________________________
In order as listed on tax return
asdasd
Address ________________________________________
Your Social Security Number (1) ____________________
asdasd
City, State, ZIP __________________________________
Your spouse's Social Security Number (2) ____________
Amount of payment ____________________________
Check number__________________________________
Date sent ______________________________________
Detach and submit the voucher below with your payment by May 17, 2004.
Individual Income Tax Electronic Filing Payment Voucher
R-540V 03
E
Name
Print in order as listed above.
Address
Your Social Security Number (1)
asdasd
City, State, ZIP
Your spouse's Social Security Number (2)
asdasd
Make payment to:
AMOUNT
Louisiana Department of Revenue
Mail date
ENCLOSED
•
P. O. Box 201
Please include your Social Security
Baton Rouge, LA 70821-0201
Number on your payment.
Do not send cash.
6222
For office use only.
62222
661
12312003
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