Form R-20127 - Claim For Refund Of Overpayment

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R-20127 (2/11)
Claim for Refund of Overpayment
Louisiana Revised Statute 47:1621 et seq.
Mail claims to the following address:
Office Audit Division
P.O. Box 66362
Baton Rouge, La 70896-6362
Telephone: (225) 219-0102
This form cannot be used as a substitute for the filing of an amended return
.
(see instructions)
PLEASE PRINT OR TYPE.
Type of Tax
Period(s)
Excise
Motor Fuels
Sales/Use
Severance
Withholding
Other__________
Taxpayer Legal Name
Louisiana Account Number
(If taxpayer is corporation, enter corporation name.)
Taxpayer Trade Name
Address
City
State
ZIP
Telephone
Represented by
(Give name and title.)
Contact Email Address
Power of Attorney Attached?
Yes
No
$
1. Total amount of tax paid for the period
$
2. Amount of tax due for the period
$
3. Amount of tax requested to be refunded
4. Less: vendor’s compensation received on
$
original return (sales tax refunds only)
$
5. Net Tax Refund Request
This refund is claimed for the following reasons:
Attach additional sheets, if necessary.
Taxpayer Signature
Date
(dd/mm/yyyy)
X

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