Form R-19023 - Request For Louisiana Tax Assessment & Lien Payoff
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1R-19023 (9/10)
Request for Louisiana Tax Assessment & Lien Payoff
Louisiana Department of Revenue
Collections Division
P.O. Box 66658
Baton Rouge, LA 70896
Telephone: (225) 219-7448
Fax: (225) 219-0864
Louisiana Revised Statutes 47:1578 provides for the cancellation of a lien when the tax, penalties and interest have been
paid. To secure the amount of payoff on a lien, please complete the form below or attach a copy of the lien(s). Response
time will normally be from 4 to 5 business days. Be sure to include the date to which you want the interest com-
puted.
You may either mail or fax this request to the address or fax number listed above. The response will be mailed to the return
address or faxed to the number you provide.
This request will not stop any applicable interest and/or penalties from accruing or cease any collection action
that is currently being taken.
Date of Request
Payoff/Interest Date
Tax Account Number
Lien Serial Number
Business Name
Taxpayer Name
Parish
Recordation Information
Reason for Request
I certify that the above-listed information is correct and the information provided will be used in payment of the lien and will
not be used for any other purpose.
Name
Title (If applicable)
Date
Company
Address
City
State
ZIP
Telephone Number
Fax Number
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