R-1021 (1/16) 

                                                                                                 Louisiana Department of Revenue
                                  Sales Tax Electronic Filing Payment Voucher                    P.O. Box 3138
                                                                                                 Baton Rouge, LA 70821-3138

Important notice
The coupon below must be used as a remittance advice by those sales tax filers who have submitted their sales tax returns through  
on-line electronic filing, and who are not required or who have not elected to submit their remittances through electronic funds transfer. 
In order to avoid the assessment of penalties and interest, remittance of the full amount due on the electronically filed return must be 
submitted to the Department on or before the 20  daythof the month following the close of the calendar month covered by the return. 
Please verify that your sales tax account number and the filing period are correctly shown in the spaces provided on the coupon. Please 
complete and retain the top portion of this form as a record of your payment. 

                               {Complete and retain this portion as a record of payment.}

                                                                                                          PLEASE PRINT OR TYPE.
Name                                                               Account number

Mailing address                                                    Filing period (MM/YY)

City                                                                                             State ZIP

                                                                   Amount of payment
     DO NOT SEND CASh.
                                                                              Check number

                                                                                     Date sent

     Detach and submit the voucher below with your payment by the 20 th          of the month following the month of the return.

R-1021 (1/16)                     Sales Tax Electronic Filing Payment Voucher
Name                                                         Account number

Mailing address                                              Filing period   (MM/YY)                                        S

City                                                                                             State ZIP

          make payment to                                                     AmOuNT 
                                         DO NOT SEND CASh.                    ENCLOSED u
Louisiana Department of Revenue
              P.O. Box 3138
     Baton Rouge, LA 70821-3138
                                                                                 FOR OFFICE uSE ONLY.
                                                                                        Mail date
                                                                                                                        1903

     19034   4358485649                            443  12312006 00000000 4376538544 
     00000500009 9