Form R-6404 - Affidavit Of Waiver Of Restrictions And Delays
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1R-6404 (1/11)
Affidavit of Waiver of Restrictions and Delays
PLEASE PRINT OR TYPE.
Taxpayer Legal Name
Louisiana Tax Account Number
Address
City
State
ZIP
Contact Person
Telephone Number
Type(s)
Tax Periods
Total Liability
AFFIDAVIT OF WAIVER OF RIGHTS, RESTRICTIONS, AND DELAYS
STATE OF
PARISH/COUNTY OF
BEFORE ME, the undersigned Notary Public in and for the Parish/County of
,
State of _____________________, comes:
Name of Affiant (Taxpayer)
Who having been duly sworn, deposed and said that:
I hereby waive all rights, restrictions, and delays for assessing, protesting, and collecting taxes and interest due to the Louisiana
Department of Revenue, as set forth in LSA R.S. 47:1562 through 1565 and 1576. I understand that this waiver makes all tax,
interest, and penalty immediately due and payable and subject to the distraint procedure provided for in Title 47 of the Louisiana
Revised Statutes.
Affiant
(please print) (Taxpayer or any officer of the corporation)
Affiant Signature
Title
Thus done and signed at ____________ (City), State of _____________________, this____________ (day) of ____________
(Month), ______ (year), in the presence of the undersigned witnesses, of the full age of majority, and me, Notary, after a full and
complete reading of the whole.
(1) Witness Name
(2) Witness
(please print)
(please print)
(1) Witness Signature
(2) Witness Signature
Notary Public Name
.
Notary Public Signature
My commission expires
(please print)
(seal)
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