Form R-19026 - Installment Request For Individual Income

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R-19026 (9/07)
Installment Request for Individual Income
This agreement cannot exceed six (6) months.
Bank Debit Application
Request must be mailed to: Louisiana Department of Revenue
Collection Division
Post Office Box 66658
Baton Rouge, La 70896-6658
Name___________________________________________ Social Security Number __________ - __________ - __________
Spouse Name_____________________________________ Social Security Number __________ - __________ - __________
Daytime Telephone Number
Name of your Financial Institution
Bank Routing Number
Bank Account Number
❏
❏
Bank Account Name _____________________
Checking
Savings
Start Date
Debit Date
Debit Amount
Signature and Verification
Under penalties of perjury, I (we) declare that the information is to the best of my (our) knowledge and belief is true, correct, and
complete. I agree to participate in this Automatic Bank Draft Program.
I also authorize the financial institutions involved in processing the electronic payment of taxes to receive confidential information
necessary to answer inquiries and resolve issues related to the payment.
Your signature___________________________________________________________
Date__________________
Spouse’s Signature________________________________________________________
Date___________________
6609

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