R-20193-L (7/16)
                                                                                       Mail Application to:
                                                                                       Louisiana Department of Revenue 
                                    Authorization Agreement for                        Central Registration
                                                                                       P.O.Box 3863
                                    ACH Credit Tax Payments                            Baton Rouge, LA  70821-3863
                                                                                       Email: CentralReg@LA.GOV
                                                                                       Fax: (225) 219-0806

 New Application (effective date):                            Change Document (effective date):

                                                                                                           PLEASE PRINT OR TYPE.
Taxpayer Name                                                                          Revenue Account Number

Tax Type – Enter the tax type name. A separate authorization is required for each tax. Federal Identification Number (if applicable)

Contact Person                      Telephone                Contact Person                                  Telephone

Mailing address for EFT purposes (street address, box number)

City                                                                                   State                 ZIP

 ACH Credit
 Before choosing the ACH Credit option, check with your financial institution to ensure that they can comply with the ACH Credit ad-
 denda record requirements as outlined in the Electronic Funds Transfer Guidelines (R-20201) available at www.revenue.louisiana.
 gov/publications. 

                                                                                       For office use only.
                                                                Effective tax period               Initials           9805