Fillable Form R-1067 - Resale Certificate Application printable pdf download

Form R-1067 - Resale Certificate Application

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R-1067 (1/10)

(

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Resale Certificate Application

La. R.S. 47:301(10)

Mail completed application to:

Louisiana Department of Revenue

Special Programs Division

Taxpayer Services

P.O. Box 66362

Baton Rouge, LA 70896

Please complete an application for each business location.

PLEASE PRINT OR TYPE.

Legal Name

Louisiana Sales Tax Account Number

Trade Name

Mailing Address

City

State

ZIP

Telephone

Location Address

City

State

ZIP

U.S. NAICS Code

U.S. NAICS Code Description

Note: U. S. NAICS Code – A United States North American Industry Classification System (NAICS) code is required on all applications. A NAICS code

should be selected that most closely describes your dominant business. Your business code may be selected from the North American Industry Classification

website at If your business has a Federal Employer Identification Number (FEIN), a NAICS code may have been assigned and may be

found on the tax return under “Business Code.”

Briefly describe business activity:

Description of items to be purchased for resale:

Authorization

I affirm that the information given on this application is true and correct.

Authorized Representative

Title

Signature

Date

(mm/dd/yyyy)