Form R-6500 - Initial Taxpayer Inquiry Regarding Refund
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1State of Louisiana
R-6500 (3/02)
Department of Revenue
Initial Taxpayer Inquiry Regarding Refund
Section I
Print your current name(s), your Social Security Number, and address including ZIP. If you filed a joint return,
show the names of both husband and wife on Lines 1 and 2 below.
1. Your name
Social Security Number
2. Spouse’s name
Social Security Number
(If a name is entered here, spouse must sign on Line 12).
3. Street
Apt. No.
City
State
ZIP
Please give us a phone number where you can be reached
Area code
Number
between 8 a.m. and 4:30 p.m. Include area code.
If any of the above has changed since you filed your tax return, please enter the information below exactly as shown on your return.
4. Name(s)
Social Security Number(s)
Street
Apt. No.
City
State
ZIP
Section II
Refund Information
(Please check all boxes that apply to you.)
5. Tax year of refund in question ____________________
6. Amount of refund in question _________________
7. ❑ I didn’t receive a refund.
❑ I received a refund check, but it was lost, stolen, or destroyed.
8. ❑ I received the refund check and signed it.
NOTE: The law doesn’t allow us to issue a replacement check if you endorsed it and someone other than you cashed
the check, since that person didn’t forge your signature.
9. ❑ I have received correspondence about the tax return.
(Please attach a copy if possible.)
(Please give us the following information if possible.)
10. ❑ Name of bank and account number where you normally cash or deposit your checks:
Bank: ___________________________________________ Account number: _________________________________
Section III
Certification
Please sign below, exactly as you signed the return. If this refund was from a joint return, we need the signatures of both
husband and wife before we can trace it.
Under penalties of perjury, I declare that I have examined this form, and to the best of my knowledge and belief, the
information is true, correct, and complete. I request that you send a replacement refund, and if I receive two refunds, I will
return one.
11. Signature
Date
12. Spouse’s signature, if required
Date
Section IV
Complete and mail to:
OR
Fax to:
Louisiana Department of Revenue
Louisiana Department of Revenue
Taxpayer Services Division
Taxpayer Services Division
P.O. Box 91017
(225) 219-2446
Baton Rouge, LA 70821-9017
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