Form R-6004 - Corporation Tax Electronic Filing Payment Voucher
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1R-6004 (1/11)
Corporation Tax Electronic
Filing Payment Voucher
Louisiana Department of Revenue
P.O. Box 91011
Baton Rouge, LA 70821-9011
Important notice
The voucher below must accompany payments made by corporation tax filers that have filed their corporation tax returns through on-line
electronic filing and that are not required to submit their payments through electronic funds transfer. In order to avoid the assessment of
penalties and interest, the full amount due on the electronically filed return must be remitted to the Department on or before the 15th day
of the fourth month following the close of the accounting period. Please provide the corporation’s Louisiana Revenue Account Number and
the filing period in the spaces provided on the voucher. Complete and retain the top portion of this form as a record of your payment.
Complete and retain this portion as a record of payment.
PLEASE PRINT OR TYPE.
Name
Louisiana Revenue Account Number
Address
Filing period (MM/YY)
City
State
ZIP
DO NOT SEND CASH.
Amount of payment
Check number
Date sent
Detach and submit the voucher below with your payment.
Corporation Tax Electronic Filing Payment Voucher
R-6004 (1/11)
Name
Louisiana Revenue Account Number
C
Address
Filing period (MM/YY)
City
State
ZIP
Make payment to
AMOUNT
u
DO NOT SEND CASH.
ENCLOSED
Louisiana Department of Revenue
P.O. Box 91011
Baton Rouge, LA 70821-9011
FOR OFFICE USE ONLY.
Mail date
1903
SPEC
CODE
19034
4358485649
243
12312006 00000000 4376538544 00000500009 9
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