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R-1362 (8/16)
Return completed form to:
Natural Disaster Claim for Refund of State Louisiana Department of Revenue
Sales Taxes Paid P.O. Box 91138
Baton Rouge, LA 70821-9138
Must attach Forms R-1362S and R-1362D
PLEASE PRINT OR TYPE.
Claimant’s Name DOB (mm/dd/yyyy) Social Security Number
Spouse’s Name DOB (mm/dd/yyyy) Spouse’s Social Security Number
Mailing Address ■ Check box to indicate address change City State ZIP
Resident of Louisiana Since (mm/yyyy) Telephone (Daytime)
Location and Description of Destruction
Street Address (including apartment number) City ZIP
Parish Date of Disaster (mm/dd/yyyy) Name or Description of Disaster
Primary Cause of Destruction: Type of Home:
■ Flood ■ Wind ■ Other_________________________ ■ House ■ Apartment/Condo ■ Mobile Home
Area(s) of the home that received damage: Total Number of Areas
■ Kitchen ■ Living Room ■ Dining Room ■ Bedroom(s) (how many rooms) ______ that Received Damage
■ Breakfast Area ■ Den ■ Garage/Carport ■ Bathroom(s) (how many rooms) ______
■ Patio ■ Outdoor Structure ■ Other ______________
1 Total amount of unreimbursed property loss from Form R-1362S, Line 3, Total Column. $
2 Total amount of state sales tax requested to be refunded from Form R-1362S, Line 6, Total Column. $
Certified Statement of Natural Disaster Refund Claim
The above individual, being duly sworn, deposes and says that the following statement is true and correct, that he is entitled to the refund
requested, and that he is not delinquent with the State of Louisiana in the payment of any state taxes.
The property described on the schedule was destroyed by a natural disaster in a “natural disaster area” so declared by the President
of the United States. I hereby certify:
• That the destroyed property was held for personal use at my residence, was not owned by a business, partnership, or corporation,
and was not otherwise used by any person for commercial purposes;
• That the property was movable, both at the time of its purchase and at the time of its destruction;
• That I paid the Louisiana state sales/use tax on my purchase of the destroyed property in the amounts now requested to be
refunded, and that the property was not acquired by gift, purchased outside the state, or otherwise without payment by me of the
Louisiana sales/use tax; and,
• That all expected and actual reimbursements from insurance and other sources have been included.
Natural disaster refund claims must be notarized to be processed. Filing or submitting false information or false representation
on this refund claim may result in jail time of 5 years and/or fines up to $5,000 under Revised Statute 14:133.
SWORN TO AND SUBSCRIBED BEFORE ME THIS _____________________ day of _____________________, ________
year
Claimant’s Name (please print) Claimant’s Signature
Spouse’s Name (please print) Spouse’s Signature
Paid Preparer Name if other than taxpayer (please print) Signature of Paid Preparer Paid Preparer Telephone Number
( )
Notary Name (please print) Notary Signature Notary Number
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