Form R-5390 - New Application Special Fuels Decal For Vehicles Using Liquefied Petroleum Gas, Compressed Natural Gas, And/or Liquefied Natural Gas

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R-5390 (12/13)
FOR OFFICE USE ONLY
Batch type = 783 or 4
SF-D New Application
Name
Special Fuels Decal for Vehicles Using
Liquefied Petroleum Gas, Compressed
Natural Gas, and/or Liquefied Natural Gas
Special Programs Division
Address
Excise Taxes Section
P.O. Box 201
City
State ZIP
Baton Rouge, LA 70821-0201
225.219.7656 • 225.219.2114 (TDD)
Excise Tax Inquiry Box: excise.inquiries@la.gov
REGISTRATION INFORMATION:
LPG
CNG
LNG
Filing Period
__________
__________
__________
6/30/2014
For Year: July 1, 2013 through June 30, 2014
Line 1.
Vehicle information:
u
A. Date purchased and/or converted
u
B. Make of vehicle
u
C. Vehicle model
u
D. Vehicle serial number
u
E. Vehicle year
u
F. Vehicle weight
(in pounds)
u
G. License number
u
H. Number of axles
u
■
I. Check here if a school bus
u
Line 2.
Amount of tax
(See instructions.)
Line 3.
If your vehicle has a gross license tax classification of more than 10,000 pounds, complete the following:
u
Odometer reading on date purchased and/or converted
u
Line 4
Penalty, if report is delinquent
(5% for each 30 days or fraction thereof, not to exceed 25% of tax)
u
Line 5.
Interest, if report is delinquent
(See instructions.)
u
Line 6.
Total due. Make check payable to: Louisiana Department of Revenue
Under the penalties of perjury, I declare that I have examined this return, including all accompanying documents, and to the best of my
knowledge and belief, is true, correct, and complete.
Date
Sign Here
Signature of preparer, if other than taxpayer
Telephone
(dd/mm/yyyy)
X
Complete Only if Vehicle Sold
Date sold
Name of Purchaser
Address
(dd/mm/yyyy)
SEPARATE APPLICATION FOR EACH VEHICLE
8303

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