Form 940c - Request For Recertification - Proof Of Credit - Louisiana Department Of Labor

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REQUEST FOR RECERTIFICATION
Return to:
(PROOF OF CREDIT – 940C)
Louisiana Dept of Labor
Office of Management & Finance
Tax Accounting/Adjustments
P. O. Box 94186
Baton Rouge, LA 70804-9186
State ID #
Federal ID #
Name of Business
Year Requested
Business is active
Business is inactive
Requested by:
EMPLOYER
FIELD
CPA/AGENT
Signature
Date
Phone #
Fax #
Comments:
This section for agency use
only.
AUTOMATE CALCULATION
MANUALLY CALCULATE
ACCOUNT #
YEAR
FED I.D.
RATE
%
TAXABLE WAGES $
CONTRIBUTIONS PAID AFTER JANUARY 31 $
CONTRIBUTIONS PAID BEFORE FEBRUARY 1 $
TOTAL CONTRIBUTIONS PAID $
(CONTINUE IF CALENDAR YEAR IS AFTER THE YEAR 1997)
FACTOR
CONTRIBUTIONS APPLIED AFTER JANUARY 31 $
CONTRIBUTIONS APPLIED BEFORE FEBRUARY 1 $
PROCESSED BY
DATE

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