Must attach Forms R-1362S and R-1362D
Claimant’s Name
Social Security Number
Spouse’s Name
Spouse’s Social Security Number
Mailing Address
Check box to indicate address change
City State ZIP
Resident of Louisiana Since
(mm/yyyy) Telephone (Daytime)
Location and Description of Destruction
Street Address (including apartment number) City ZIP
Parish Date of Disaster
(mm/dd/yyyy) Name or Description of Disaster
Primary Cause of Destruction:
Flood Wind Other_________________________
Type of Home:
House Apartment/Condo Mobile Home
Area(s) of the home that received damage:
Kitchen Living Room Dining Room Bedroom(s) (how many rooms) ______
Breakfast Area Den Garage/Carport Bathroom(s) (how many rooms) ______
Patio Outdoor Structure Other ______________
Total Number of Areas
that Received Damage
1 Total amount of unreimbursed property loss from Form R-1362S, Line 3, Total Column.
2 Total amount of state sales tax requested to be refunded from Form R-1362S, Line 6, Total Column.
Certified Statement of Natural Disaster Refund Claim
The above individual, being duly sworn, deposes and says that the following statement is true and correct, that he is entitled to the refund
requested, and that he is not delinquent with the State of Louisiana in the payment of any state taxes.
The property described on the schedule was destroyed by a natural disaster in a “natural disaster area” so declared by the President
of the United States. I hereby certify:
That the destroyed property was held for personal use at my residence, was not owned by a business, partnership, or corporation,
and was not otherwise used by any person for commercial purposes;
That the property was movable, both at the time of its purchase and at the time of its destruction;
That I paid the Louisiana state sales/use tax on my purchase of the destroyed property in the amounts now requested to be
refunded, and that the property was not acquired by gift, purchased outside the state, or otherwise without payment by me of the
Louisiana sales/use tax; and,
That all expected and actual reimbursements from insurance and other sources have been included.
Natural disaster refund claims must be notarized to be processed. Filing or submitting false information or false representation
on this refund claim may result in jail time of 5 years and/or nes up to $5,000 under Revised Statute 14:133.
_____________________ day of _____________________, ________
Claimant’s Name (please print)
Claimant’s Signature
Spouse’s Name
(please print)
Spouse’s Signature
Paid Preparer Name if other than taxpayer
(please print)
Signature of Paid Preparer Paid Preparer Telephone Number
( )
Notary Name (please print)
Notary Signature Notary Number
R-1362 (8/16)
Natural Disaster Claim for Refund of State
Sales Taxes Paid
Return completed form to:
Louisiana Department of Revenue
P.O. Box 91138
Baton Rouge, LA 70821-9138
Page 1 of 3
Claimant’s Name Social Security Number
Spouses Name Spouses Social Security Number
Name or Description of Disaster Date of Disaster (mm/dd/yyyy)
Location Where Property was Destroyed
Street Address City Parish State ZIP
Calculation of State Sales Tax Refund Due
R-1362D, Column A
4% tax rate
R-1329D, Column B
5% tax rate
(Column A + B)
Total cost of destroyed property from attached Form(s)
$ $ $
2 Reimbursement of destroyed property
Reimbursement from insurance – actual or anticipated
Check box if destroyed property was not covered by
($ ) ($ ) ($ )
Reimbursement from employer or disaster relief agencies
Check box if you were denied reimbursement from an
Check box if you were denied reimbursement from any
disaster relief agencies, including FEMA.
($ ) ($ ) ($ )
Total reimbursement – Add Lines 2a and 2b for Columns A
and B.
($ ) ($ ) ($ )
Total unreimbursed property loss – Subtract Line 2C from
Line 1 for Columns A and B.
$ $ $
4 State sales tax rate
4% 5%
State sales tax computation – Multiply Line 3 by the sales tax
rates found on Line 4 for Columns A and B.
$ $
Total state sales tax refund requested. Add Line 5,
Columns A and B.
Page 2 of 3
R-1362S (8/16)
Natural Disaster Claim for Refund
Calculation of State Sales Tax Refund Due
Must be attached to Natural
Disaster Claim for Refund of State
Sales Taxes Paid – Form R-1362
Claimant’s Name Social Security Number
Spouses Name Spouses Social Security Number
The following are examples of tangible personal property that would be eligible for the state sales tax refund:
1. Furniture, Rugs, Utensils, etc.
2. TV, Camera, Toys, Exercise Equipment, etc.
3. Clothing, Linens, etc.
4. Other Household Items (Books, Decorations, Lawn Mowers, etc.)
The following items are not eligible for state sales tax refunds:
1. Food
2. Real immovable property, such as houses, buildings, central heating and cooling systems, lighting fixtures, lavatories, dishwashers,
water heaters, hot tubs and spas, and wall-to-wall carpeting.
3. Titled assets such as automobiles or all terrain vehicles (ATV).
4. Boats, water or snow skis, golfing or tennis equipment or other recreation equipment generally used away from the home.
To support your claim, attach a copy of the declaration page of your homeowner’s or renter’s insurance policy and a copy of the
insurance adjuster’s report that documents the damage and claim reimbursement amounts. If you did not have insurance, attach
all available purchase receipts for the destroyed items and any documentation of reimbursement from FEMA or other disaster relief
sources. Attach copies of any letter from insurance copy, FEMA, or other disaster relief agencies showing denial of reimbursement.
Description of Property
Date of
Original Cost of Property
Purchased PRIOR TO
APRIL 1, 2016
Original cost of Property
Purchased ON or AFTER
APRIL 1, 2016
Total Property Cost (Total columns A and B.)
If more space is needed, additional copies of this form may be used.
Page 3 of 3
R-1362D (8/16)
Schedule of Tangible Personal
Property Destroyed by a Natural Disaster
Must be attached to Natural
Disaster Claim for Refund of State
Sales Taxes Paid – Form R-1362