Form R-5403 - Supplier/permissive Supplier - Notification Of Unpaid Tax By Licensed Distributor Or Licensed Importer

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R-5403 (7/06)
Page __________ of ___________
Supplier/Permissive Supplier – Notification of
Unpaid Tax by Licensed Distributor or
Licensed Importer
Taxpayer Services Division
Excise Taxes Section
P. O. Box 66362
Baton Rouge, LA 70896-6362
Company Name
LA Revenue Account Number
Date
Month of Purchase
Address
Telephone Number
City
State
ZIP
Fax Number
Product Type
065 – Gasoline
123 - Alcohol
124 – Gasohol
160 – Clear Diesel
142 – Clear Kerosene
170 – Clear Biodiesel Other ____________________________________
(2)
(1)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
Licensed Distributor/Importer
Date
Product
Document
Net Taxable
Amount Due
Purchased
Type
Number
Gallons
(before discount)
Amount Paid
Date Paid
Comments
Name
Rev. ID
I declare and affirm under penalties of perjury that this notification has been examined by me, and to the best of my knowledge and belief is a true and complete notification made in good faith covering
the month named and that same is in accordance with the books and records of the reporting trustee.
Date
Signature
Title

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