R-540V (1/13)
2012
Individual Income Tax Electronic
Filing Payment Voucher
Louisiana Department of Revenue
P.O. Box 3550
Baton Rouge, LA 70821-3550
IMPORTANT NOTICE
Tax preparers should provide this form to clients who file electronically if a payment is due with the return. Taxpayer clients
who owe additional Louisiana individual income tax for 2012 must complete the payment voucher at the bottom of this
page, detach the voucher, and mail it by May 15, 2013, in order to avoid the assessment of penalties and interest. The top
portion of this form should also be completed and retained by the taxpayer as a record of payment.
• DO NOT SEND CASH.
•
Complete and retain this portion as a record of payment.
• You can also make payments via the internet. Go to
Your Name
If joint return, spouse’s name
Address
City
State
ZIP
Print in order as listed on tax return
Your Social Security Number
A m o un t o f p a ym e n t
Spouse’s Social Security Number
Check Number
Date Sent
Detach and submit the voucher below with your payment by May 15, 2013.
2012
R-540V (1/13)
INDIVIDUAL INCOME TAX ELECTRONIC FILING PAYMENT VOUCHER
Your Name
PLEASE PRINT OR TYPE.
E
If joint return, spouse’s name
Address
DO NOT SEND CASH.
Amount of payment.
City
State
ZIP
$
Print in order as listed on tax return.
Make payment to:
Please include your Social Security
Your Social Security Number
Number on your payment.
Louisiana Department of Revenue
Spouse’s Social Security Number
P. O. Box 3550
Baton Rouge, LA 70821-3550
Mail date
SPEC
1903
CODE
For office use only
19034
663
12312012