Form R-7004 - Tax Information Disclosure Authorization

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R-7004 (6/09)

For LDR Use Only

Received by

Tax Information Disclosure

Authorization

Name

Division

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Telephone

Date

PLEASE PRINT OR TYPE.

1. Taxpayer Information

— Ta x p a y e r m u st s i g n a n d d a t e t h i s fo r m.

Name

Social Security Number

If joint return. Spouse’s Name

Spouse’s Social Security Number

Address

LA Revenue Account Number

Federal Employer ID Number

City

State

ZIP

Daytime Telephone Number

2. Appointee

— I f y ou w ant t o n a m e m o r e t h a n o n e a p p o i n t e e , a t t a c h a l i s t t o t h i s f o r m.

Name

Telephone Number

Address

Fax Number

City

State

ZIP

E-mail Address

T h e a p p o i n t e e i s a u t h o r i ze d t o i n s pe c t a nd r e c e i v e c o n f i d e n t i a l t a x i n f o r m a t i o n i n a n y o f f ic e of t h e

3. Tax Matters

—

Louis ian a De p a r t m e n t o f Re v e n u e f o r t h e t a x m a t t e r s l i s t e d b e l o w .

Tax Type

Tax Form Number

Tax Year or Period

Specific Tax Matters

. If a tax matter applies to a joint return,

husband and wife must sign.

Signature of taxpayer(s)

both

I certify that I have the authority to execute this form with respect to the tax matters/periods on Line 3 above.