R-20128 (12/02)
                                                    State of Louisiana
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Request for Waiver of Penalty for Delinquency

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Request for Waiver of Penalty for Delinquency

  1. 1. R-20128 (12/02) State of Louisiana Department of Revenue P. O. Box 201 Baton Rouge, LA 70821-0201 REQUEST FOR WAIVER OF PENALTIES FOR DELINQUENCY Taxpayer _____________________________________________________________________________ Account number _____________________________________________________________________________ Tax _____________________________________________________________________________ Period(s) _____________________________________________________________________________ Type of Penalty _____________ Delinquent _____________ Late Payment I hereby assert that the delinquency in filing the subject return and/or paying the subject tax was not due to my intent to violate the law, but was due to the following reason(s): Pursuant to the provisions of Louisiana Revised Statute 47:1603 and based on the causes described in the preceding paragraph, request is hereby made that the penalties of $________________ incurred under the provisions of R. S. 47:1602 be waived. Under the penalty of perjury, I declare all of the facts alleged above as a basis for reasonable cause, to the best of my knowledge and belief, including all accompanying documentation, are true, correct, and complete. Signature ______________________________________________ Date _____________________________________ ______________________________________________ (OFFICAL TITLE IF ACTING FOR A CORPORATION)

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