R-20127 (8/16)
Mail to:
Louisiana Department of Revenue
Taxpayer Compliance Division-SSEW
Claim for Refund of Overpayment
P.O. Box 66362
Louisiana Revised Statute 47:1621 et seq.
Baton Rouge, LA 70896-6362
Phone: (225) 219-2270
Email:
LDRTax.Refunds@LA.gov
This form cannot be used as a substitute for the filing of an amended return
.
(see instructions)
PLEASE PRINT OR TYPE.
Type of Tax
Period(s)
Excise
Motor Fuels
Sales/Use
Withholding
Other__________________
Louisiana Account Number
Taxpayer Legal Name (If taxpayer is corporation, enter corporation name.)
Taxpayer Trade Name
Telephone
Address
City
State
ZIP
Represented by (Give name and title.)
Contact Email Address
Power of Attorney Attached?
Yes
No
$
1. Total amount of tax paid for the period
$
2. Amount of tax due for the period
$
3. Amount of tax requested to be refunded
4. Less: vendor’s compensation received on
original return (sales tax refunds only) for:
$
A. Periods prior to July 2013
_________________________________________________________________
$
B. Periods July 2013 to March 2016
_________________________________________________________________
$
C. Periods April 2016 going forward
_________________________________________________________________
Total vendor’s compensation
received on original return
$
_________________________________________________________________
(Total Lines A, B, and C)
$
5. Net Tax Refund Request
This refund is claimed for the following reasons:
Under penalty of perjury, I declare that I have examined this claim for refund and accompanying documents, and to the best of my knowledge and belief it is true, correct, and complete.
Taxpayer Signature
Date
(dd/mm/yyyy)