R-3406 (1/11)
                  Request to Close Business Tax Accounts
                  Request must be mailed or faxed to:
                  Louisiana Department of Revenue
                  Revenue Processing Center
                  P.O. Box 201
                  Baton Rouge, LA 70821
                  (225) 219-7462 (telephone)   (225) 219-0806 (fax)

Note: A separate form is not necessary if the change applies to all taxes.

Legal Name

Trade Name

Address                                City                                              State ZIP

I hereby authorize the following account(s) be closed:
                                                                          Account Number          Close Date (mm/dd/yyyy)
■ Sales 

                                                                          Account Number          Close Date (mm/dd/yyyy)
■ Withholding

                                                                          Account Number          Close Date (mm/dd/yyyy)
■ Severance

                                                                          Account Number          Close Date (mm/dd/yyyy)
■ Other *(Specify)  _________________________________________

*  Tax accounts other than the types listed above may require additional documentation for closure. Please contact the Louisiana De-
partment of Revenue for more information regarding documentation requirements.

                                                      Authorization
Contact Person                                        Daytime Telephone Number

Signature                                             Date (mm/dd/yyyy)

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