R-19026 (9/21)
                                                                         Louisiana Department of Revenue
                                                                         Collection Division
                                                   Installment Request  
                                                                         P.O. Box 66658
                                                   for Individual Income Baton Rouge, LA 70896-6658
                                                                         Telephone: (855) 307-3893

Monthly installments are available to taxpayers who are unable to pay the full balance owed by the due date. During this period, you 
must submit monthly equal payments of the total balance due. THIS AGREEMENT MUST BE A MINIMUM OF SIX (6) MONTHS AND 
CANNOT EXCEED 36 MONTHS. 

How to request an installment agreement
To apply for an installment agreement, do not submit this form with your return. Complete pages 2 and 3, and mail the forms to:
Louisiana Department of Revenue
P. O. Box 66658
Baton Rouge, LA 70896-6658
Any missing or incomplete information will cause the request to be denied. All information will be verified. An initial payment of 20  
percent of the amount due is required to complete the request. You may also submit the request by accessing your account at  
www.revenue.louisiana.gov/latap.

Fee for installment agreement 
There is a fee for an installment agreement of $105. If we approve your request, we will send you a notice detailing the terms of your 
agreement and will add the installment fee of $105 to the total balance due. However, you will not be charged a fee if your adjusted gross 
income is less than or equal to $25,000. LDR will let you know whether you qualify for the reduced fee.
Note: Do not file this form if you are currently making payments on an installment agreement
When to make payments
When the installment agreement request has been approved, you will be notified. However, you should make monthly payments even if 
you have not received a response from the Department.
During the existence of this agreement, you must file all state tax returns and pay all state taxes timely.

How to make payments
We require the use of automatic bank debit for payment of the agreement. With the bank debit, payments will be withdrawn from your 
checking or savings account on the date you specify. Failure to have sufficient funds in your account at the time of debit will result in an 
NSF fee being added to the balance due and result in your agreement being cancelled. The application for automatic bank debit is on 
page 3 of this form.  
Will I continue receiving bills?
The normal billing process will continue. A part of that process is the issuance of a “Notice of Intent”. Failure to make the scheduled 
monthly payment will result in seizure of bank accounts and/or garnishment of your wages. Please ensure that the last four digits of your 
social security number is written on your check or money order.
An approved installment agreement WILL NOT PREVENT the garnishment of any refund due from the Internal Revenue Service or LDR. 
To protect the State’s interest, a Tax Assessment and Lien may be filed.

What if I miss a payment?
If any installment payment is not paid on or before the date fixed for its payment, you will be considered in default of your agreement and 
the total outstanding balance is immediately due. At this point, all collection actions will be reactivated. You may contact the department 
to request reinstatement of your installment agreement at which time a reinstatement fee of $60 is due. 

What if I do not stay current with my taxes and returns?
If you do not stay current in your obligations to the state, you will be considered in default of your agreement and the total outstanding 
balance is immediately due. At this point, all collection actions will be reactivated. You may contact the department to request 
reinstatement of your installment agreement at which time a reinstatement fee of $60 is due.
Contact Information 
If you have questions about an installment request, contact the Collection Division at (855) 307-3893. If your request is approved, you 
will need to contact the Collection Division to determine the amount of the final payment since penalty, interest and collection fees will 
accrue until the tax is paid in full.

R-19026 (9/21)
                                                                                                                                                             I
                                                                                                                              Mail to:
                                                                                                                              Louisiana Department of Revenue
                                           Installment Request  
                                                                                                                              Collection Division
                                           for Individual Income                                                              P.O. Box 66658
                                                                                                                              Baton Rouge, LA 70896-6658

                                                                                                                                      PLEASE PRINT OR TYPE
Full Name

Social Security Number                     Home Phone                                                                         Cell Phone

Current Address (number and street)                                          Unit Type                                                Unit Number

City                                                                                                                          State   ZIP

Employer                                                                                                                      Date of Hire  (mm/dd/yyyy)

Employer’s Address                                                                                                            Gross Weekly Wage

Spouse’s Name                                                                                                                 Spouse’s Social Security Number

Spouse’s Employer                                                                                                             Date of Hire  (mm/dd/yyyy)

Spouse’s Employer Address                                                                                                     Gross Weekly Wage

Name of Bank (Personal)                    Bank Account Number                                                                Bank Routing Number

Name of Bank (Business)                    Bank Account Number                                                                Bank Routing Number

Tax periods to be included:                Date you wish to make your monthly payments:

1. Total amount due                                                                                                                   $

2. Amount of initial payment to be made with application. Multiply Line 1 by 20 percent (.20).                                        $

3. Balance to be paid over length of agreement. Subtract Line 2 from Line 1.                                                          $

4. Monthly payments. Divide Line 3 by the number of months agreed. Months agreed upon: ___________                                    $
         THIS AGREEMENT MUST BE A MINIMUM OF SIX (6) MONTHS AND CANNOT EXCEED 36 MONTHS.
Initial  Spouse Initial
                            I/we expressly waive the restrictions and delays prescribed in LA R.S. 47:1562 through 47:1565 and acknowledge that upon execution of this 
                            agreement the liabilities identified herein shall become final and immediately collectible.
                            I/we expressly waive any right to appeal or otherwise challenge the liabilities identified herein.

                            I/we expressly waive any right to seek a refund of any amounts paid in connection with this agreement.

                            I/we acknowledge that an approved installment agreement will not prevent the garnishment of any refund due from the IRS or LDR.
                            I/we agree to timely file all returns and pay all taxes that become due and acknowledge that failure to do so will be considered a default under 
                            this agreement.
Under the penalties of perjury, I declare that I have examined the Request for Payment Arrangement form, including all 
accompanying documents, and hereby affirm that to the best of my knowledge and belief, it is true, correct, and complete.
Your Signature                             Date (mm/dd/yyyy)

Spouse’s Signature                         Date (mm/dd/yyyy)

R-19026 (9/21) 
                                                                                                                                                            I
                                                                                                    Mail to:
                                                                                                    Louisiana Department of Revenue
                                                    Installment Request for Individual
                                                                                                    Collection Division
                                                    Income Bank Debit Application                   P.O. Box 66658
                                                                                                    Baton Rouge, LA 70896-6658

Name                                                                         Social Security Number             Daytime Telephone Number

Spouse Name                                                                  Social Security Number

Name of your Financial Institution

Bank Routing Number                                                          Bank Account Number

Bank Account Name
                                                                             ■ Checking  ■ Savings
Start Date (mm/dd/yyyyy)                            Debit Date (mm/dd/yyyyy)                        Debit Amount

                                                 NOTE: PLEASE ATTACH A VOIDED CHECK.

                                                    Signature and Verification
Under penalties of perjury, I (we) declare that the information is to the best of my (our) knowledge and belief is true, correct, and complete. I agree to  
participate in this Automatic Bank Draft Program.
I also authorize the financial institutions involved in processing the electronic payment of taxes to receive confidential information necessary to answer  
inquiries and resolve issues related to the payment.
Your Signature                                                                                      Date         (mm/dd/yyyy)

Spouse’s Signature                                                                                  Date         (mm/dd/yyyy)