Taxpayer
Account Number Tax Period(s)
Type of Penalty
Delinquent Filing ☐ Delinquent Payment ☐ Underpayment of Estimated Tax ☐ Other ☐
I hereby declare that the delinquency in ling the subject return and/or paying the subject tax was not due to my intent to violate any law,
but was due to the following reason(s):
Pursuant to the provisions of R.S. 47:1603 and based on the facts stated above, request is hereby made that payment of penalties in
the amount of $ ____________________ imposed in accordance with a taxing statute be waived.
Under penalty of perjury, under the laws of the State of Louisiana, I certify that all statements contained in this request for waiver of penalties and any and
all accompanying documents are true and correct to the best of my knowledge and belief.
Date
(mm/dd/yyyy) Signature Official Title (if acting for a corporation)
PLEASE PRINT OR TYPE.
R-20128 (10/13)
Request for Waiver of Penalties
Louisiana Department of Revenue
P.O. Box 201
Baton Rouge, LA 70821-0201
Louisiana Administrative Code 61:III.2101.B provides that before a request for waiver of penalties can be considered, the taxpayer must
be current in ling all tax returns, and all taxes, penalties not being considered for waiver, fees and interest due for any taxes/fees
administered by the Louisiana Department of Revenue must be paid.
