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Get and Sign R20128 2016-2022 Form
Number
Tax
Type of Penalty
Delinquent Filing
☐
Delinquent Payment
Period(s)
☐
Underpayment of Estimated Tax
☐
Other
☐
I hereby declare that the delinquency in filing 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 $ __________________________...
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