Form R-1012 - Direct Payment Authorization For Call Centers Application

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R-1012 (8/11)
Direct Payment Authorization
For Call Centers Application
Louisiana R.S. 47:301(14)(ii(ii)(cc)(III)
Mail applications to:
Louisiana Department of Revenue
Special Programs Division
P.O. Box 66362
Baton Rouge, LA 70821-6362
(225) 219-7462 Option 3 • (TDD)(225) 219-2114
FAX: (225) 219-6236
PLEASE PRINT OR TYPE.
Legal Name
LDR Business Master File
Account Number
Trade Name
Mailing Address
City
State
ZIP
Location Address(es)
(Attach additional pages if necessary.)
Location 1: street address
City
State
ZIP
Location 2: street address
City
State
ZIP
Location 3: street address
City
State
ZIP
Describe the principal income producing activity of your business
List the names, addresses, and Business Master File Account Numbers of your subsidiaries that operate as call centers in Louisiana.
(Add additional
pages if necessary.)
Subsidiary Name
Louisiana Revenue Account Number
Location address
City
State
ZIP
Subsidiary Name
Louisiana Revenue Account Number
Location address
City
State
ZIP
Subsidiary Name
Louisiana Revenue Account Number
Location address
City
State
ZIP
Authorized Officer (please print)
Title
Signature
Date
Telephone
(mm/dd/yyyy)

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