Form R-19026 - Installment Request For Individual Income - 2016
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R-19026 (8/16)
Mail to:
Installment Request
Louisiana Department of Revenue
P. O. Box 66658
for Individual Income
Baton Rouge, LA 70896-6658
PLEASE PRINT OR TYPE.
Full Name
Social Security Number
FEIN
(If Applicable)
City
State
ZIP
Home Phone
Cell Phone
Employer
Employer’s Address
Date of Hire
Gross Weekly Wage
(mm/dd/yyyy)
Spouse’s Name
Spouse’s Social Security Number
Spouse’s Employer
Spouse’s Employer Address
Date of Hire
Gross Weekly Wage
(mm/dd/yyyy)
Name of Bank
(Personal)
Bank Account Number
Bank Routing Number
Name of Bank
(Business)
Bank Account Number
Bank Routing Number
Tax periods to be included:
Date you wish to make your monthly payments:
1. Total amount due
$
2. Amount of initial payment to be made with application. Multiply Line 1 by 20 percent (.20).
$
3. Balance to be paid over length of agreement. Subtract Line 2 from Line 1.
$
4. Monthly payments. Divide Line 3 by the number of months agreed. Months agreed upon: ___________
$
THIS AGREEMENT MUST BE A MINIMUM OF SIX (6) MONTHS AND CANNOT EXCEED TWELVE (12) MONTHS.
Under the penalties of perjury, I declare that I have examined the Request for Payment Arrangement form, including all
accompanying documents, and hereby affirm that to the best of my knowledge and belief, it is true, correct, and complete.
Your Signature
(mm/dd/yyyy)
Date
Spouse’s Signature
(mm/dd/yyyy)
Date
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