Form R-8352mj - Affidavit Of Fraudulent Refund Deposit For Married Filing Jointly Filing Status

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R-8352MJ (8/08)
Louisiana Department of Revenue
Affidavit of Fraudulent Refund Deposit
for Married Filing Jointly Filing Status
Notice: The person alleging fraud must execute the affidavit in the presence of the Notary Public.
State of
Parish/County of
1. We are first duly sworn and state that our names are:
Taxpayer’s First Name
Middle Init.
Last Name
Taxpayer’s SSN
Spouse’s First Name
Middle Init.
Last Name
Spouse’s SSN
Mailing Address
Email Address
City
State
Zip
Primary Telephone Number
Secondary Telephone Number
2. We state that the Louisiana Department of Revenue refund deposit listed below was not authorized by us and was fraudulently
deposited as described below without our knowledge or authorization.
Bank where the refund was deposited.
Bank account where the refund was deposited.
Deposit date
Deposit amount
Taxpayer’s Bank
Bank Account No.
Account status at the time of fraud
Taxpayer’s
Open
Closed
Bank Account No
Spouse’s Bank
Account status at the time of fraud
Spouse’s
Open
Closed
3. We state that we did not receive any part of the proceeds of this deposit, directly or indirectly, and that this affidavit is made volun-
tarily for the purpose of establishing the fact that the deposit was made fraudulently without our knowledge or authorization.
4. Do you know who fraudulently deposited the refund?
No.
Yes. If yes, provide details.
5. We understand this fraud is subject to investigation by local, state and federal law enforcement agencies and that we may be required
to comply with a court order or subpoena to give testimony.
6. We understand making a false sworn statement is subject to federal and state statutes and may be punishable by fines and/or by imprisonment.
Thus Sworn to and Subscribed Before Me, Notary, in the presence of the undersigned two witnesses, who personally came and appeared,
on this ________ day of ________________, 20____.
Taxpayer’s Signature
Spouse’s Signature
Signature of witness
Notary
Print witness name
Print name of Notary and Notary Number
(Must include seal)
Signature of witness
Print witness name

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