R-540V-SD (1/17) 

                                        Individual Income Tax Electronic    Louisiana Department of Revenue
                                                                            P.O. Box 3550
                                         Filing Payment Voucher (2016)      Baton Rouge, LA  70821-3550

IMPORTANT NOTICE
Tax preparers should provide this form to clients who file electronically if a payment is due with the return. Taxpayer clients 
who owe additional Louisiana individual income tax for 2016 must complete the payment voucher at the bottom of this 
page, detach the voucher, and mail it by May 15, 2017, in order to avoid the assessment of penalties and interest. The top 
portion of this form should also be completed and retained by the taxpayer as a record of payment.

• DO NOT SEND CASH.

•    Complete and retain this portion as a record of payment.

•    You can also make payments via the internet. Go to   www.revenue.louisiana.gov/fileonline

Your Name

If joint return, spouse’s name

Address

City                                                                        State                    ZIP

                                                                          Amount of payment
Enter in order as listed on tax return
Your Social Security Number                                                                             .
                                                                          Check Number
Spouse’s Social Security Number
                                                                          Date Sent

                               Detach and submit the voucher below with your payment by May 15, 2017.
R-540V-SD (1/17)
                 INDIVIDUAL INCOME TAX ELECTRONIC FILING PAYMENT VOUCHER                                2016
Your Name                                                                PLEASE PRINT OR TYPE.
If joint return, spouse’s name                                                                              E
Address
City                                    State ZIP                         Amount of payment.    DO NOT SEND CASH.

Enter in order as listed on tax return.                                   $                             .
Your Social Security Number              Make payment to:                 Please include your Social Security 
                                         Louisiana Department of Revenue  Number on your payment.
Spouse’s Social Security Number          P. O. Box 3550
                                         Baton Rouge, LA  70821-3550
                                                                            Mail date
                                              SPEC                                                      1903
                                              CODE
                                                                          For office use only