R-20127 (8/16)
                                                                                                                       Mail to:
                                                                                                                       Louisiana Department of Revenue
                                        Claim for Refund of Overpayment                                                Taxpayer Compliance Division-SSEW
                                                                                                                       P.O. Box 66362
                                        Louisiana Revised Statute 47:1621 et seq.
                                                                                                                       Baton Rouge, LA  70896-6362
                                                                                                                       Phone:  (225) 219-2270
                                                                                                                       Email:  LDRTax.Refunds@LA.gov

            This form cannot be used as a substitute for the filing of an amended return                                       (see instructions).

                                                                                                                                     PLEASE PRINT OR TYPE.
Type of Tax                                                                                                            Period(s)
Excise         Motor Fuels           Sales/Use       Withholding          Other__________________
Taxpayer Legal Name (If taxpayer is corporation, enter corporation name.)                                              Louisiana Account Number

Taxpayer Trade Name                                                                                                    Telephone

Address

City                                                                                                                           State ZIP

Represented by (Give name and title.)

Contact Email Address                                                                                                  Power of Attorney Attached?
                                                                                                                               Yes       No

1.  Total amount of tax paid for the period         $

2.  Amount of tax due for the period                $

3.  Amount of tax requested to be refunded          $

4.  Less: vendor’s compensation received on
       original return (sales tax refunds only) for:
       A.  Periods prior to July 2013               $ _________________________________________________________________
       B.  Periods July 2013 to March 2016          $ _________________________________________________________________
       C.  Periods April 2016 going forward         $ _________________________________________________________________
              Total vendor’s compensation
              received on original return
              (Total Lines A, B, and C)             $ _________________________________________________________________

5.  Net Tax Refund Request                          $

This refund is claimed for the following reasons:

Under penalty of perjury, I declare that I have examined this claim for refund and accompanying documents, and to the best of my knowledge and belief it is true, correct, and complete.
Taxpayer Signature                                                        Date (dd/mm/yyyy)

                                                          INSTRUCTIONS
                                         Claim for Refund of Overpayment (R-20127)

General Information
The Louisiana Department of Revenue has limited authority to issue refunds of overpayments. The Department can only refund an 
overpayment if there is express statutory authority to issue the refund.

Act 446 (HB 756) of the 2016 Regular Session enacted R.S. 47:1520.2 to require electronic filing of all schedules and invoices for all sales 
tax refund claims of $25,000 or more and for all refund claims made by a tax preparer on behalf of the taxpayer, regardless of the amount 
of the refund requested.  See Revenue Information Bulletin No. 16-040. Send an email to LDRTax.Refunds@LA.gov to request that a secure 
portal be opened for sending documentation electronically.

If your refund request is a natural disaster refund request, you must use Form R-1362, or a pollution control device refund, you must use 
Form R-1050.  These forms are available on our website or by contacting the Department. 

This form should be used to file refund claims for Excise tax, Motor Fuels tax, Sales/Use tax, Withholding tax and certain other taxes 
designated by the Taxpayer Compliance Division. Do not use this form as a substitute for the filing of an amended return or to correct an error 
on a previously filed tax return. Claims for refunds of Severance Tax must be filed electronically in the form of an amended return.

Amended sales/use tax returns should be filed for the following reasons:
1. Gross sales of tangible personal property reported on Line 1 are greater or less than reported on the original return.
2.  Cost of tangible personal property reported on Line 2 is greater or less than reported on the original return.
3.  Leases, rentals, or services reported on Line 3 are greater or less than reported on the original return.
4.  Total allowable deductions as reported on Line 5 (Schedule A) are greater or less than reported on the original return.
5.  Excess tax collected on Line 8 is greater or less than reported on the original return.
6.  If for any reason, the amounts reported on an original sales and use tax return change, an amended return must be filed.

Specific Instructions
1. Check the appropriate tax box.
2.  Fill in the tax periods included in the refund claim.
3.  Taxpayer’s Legal name. If the taxpayer is a corporation, enter the legal corporation name.
4.  Louisiana revenue account number – self-explanatory.
5.  Taxpayer’s trade name.
6.  Business street address – self-explanatory.
7. City, State, Zip Code – self-explanatory.
8.  Telephone – telephone contact number of claimant and/or claimant’s representative.
9.  Name of claimant or business hired to submit claim information. Please submit a power of attorney form with the refund claim.
10.  Contact email address - self-explanatory.
11.  Box 1 – total tax paid on the original return for the periods listed on the claim form.
12.  Box 2 – total tax actually due for the periods listed on the claim form.
13.  Box 3 – requested refund amount.
14.  Box 4 – subtract vendor’s compensation received on original return. This box applies only if the original sales/use tax return was 
   filed and paid timely. Due to different rates, separate vendor’s compensation for (A) periods prior to July 2013, (B) periods July 
   2013 to March 2016, and (C) periods starting April 2016 going forward.
15.  Box 5 - Net Tax Refund Request – self-explanatory.
16.  State reasons for refund request.

Please sign and date your refund request.