Form R-1114 - Orthopedic Disability Sales Tax Rebate Claim
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2R-1114 (8/11)
Orthopedic Disability
Sales Tax Rebate Claim
Louisiana Revised Statute 47:305.69
Mail to:
Office Audit Division
Economic Development Unit
P. O. Box 66362
Baton Rouge, LA 70896-6362
(225) 219-2270
Please see the back of this form for rebate claim filing information.
Please print or type.
Claimant Information
Name
Driver’s License No.
Social Security Number
Date of Claim
(Last 4 Digits)
(mm/dd/yyyy)
XXX-XX-
____ ____ ____ ____
Mailing Address
City
State
ZIP
Contact Number
(
)
Relationship to Orthopedically Disabled Person
■
■
Self
Other (list)
_______________________________________________________________________________________________________________________________________
Orthopedically Disabled Person Information
Name
Driver’s License No.
Social Security Number
Date of Disability
(Last 4 Digits)
(mm/dd/yyyy)
XXX-XX-
____ ____ ____ ____
Mailing Address
City
State
ZIP
Contact Number
(
)
Description of Disability
Motor Vehicle Information
Make
Model
Year
VIN Number
Description of Modifications Performed
Purchase Date of Vehicle
Louisiana Sales Tax Paid
(mm/dd/yyyy)
Please attach requested documentation. See the back of the rebate claim form for documentation information
Declaration
I declare that to the best of my knowledge of all available information, this rebate claim is true and complete and complies with all statutes, rules and
regulations, and any other policy pronouncements related to the Orthopedic Disability Rebate program.
Signature of Claimant
Name
(Please Print)
Date
(mm/dd/yyyy)
Department of Health and Hospitals Review
Signature
Date
(mm/dd/yyyy)
Printed Name
Printed Title
Louisiana Department of Revenue Approval
Signature
Date
(mm/dd/yyyy)
■
■
Approved
Disapproved
Printed Name
Printed Title
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