R-7004 (12/16)

                                                                                               Louisiana Department of Revenue 
                                Tax Information Disclosure Authorization                       P.O. Box 201
                                                                                               Baton Rouge, LA 70821

1.  Taxpayer Information — Taxpayer must sign and date this form.
Name                                                            Social Security Number

If joint return. Spouse’s Name                                  Spouse’s Social Security Number

Address                                                         LA Revenue Account Number      Federal Employer ID Number

City                                 State    ZIP               Daytime Telephone Number

2. Appointee —  If you want to name more than one appointee, attach a list to this form.
Name                                                            Telephone Number

Address                                                         Fax Number

City                                                                                            State ZIP

                      The appointee is authorized to inspect and receive confidential tax information in any office of the 
3. Tax Matters — 
                      Louisiana Department of Revenue for the tax matters listed below.
              a                            b                                   c                                    d
           Tax Type             Tax Form Number                       Tax Year or Period        Specific Tax Matters

4. Fees
                                                                                                                    C
                                           A                                   B
                                                                                                Total Fee Due (Multiple 
                                Number of Tax Years or Period              Fee
                                                                                                Column A by Column B)
If you are requesting copies of 
returns listed above:                                                      $15.00
If you are requesting CERTIFIED 
copies of returns listed above:                                            $25.00

Total Amount Due - Add amounts in Column C.
                                                                                               $
Make payment to: Louisiana Department of Revenue. Do not send cash. PAY THIS AMOUNT

5. Signature of taxpayer(s).    If a tax matter applies to a joint return, both husband and wife must sign.
I certify that I have the authority to execute this form with respect to the tax matters/periods in Section 3 above.
Signature                                                       Signature (Spouse)

Print Name                                                      Print Name (Spouse)

Title                                         Date (mm/dd/yyyy) Title                                               Date (mm/dd/yyyy)

   If not signed and dated, this tax information disclosure authorization will be returned. If payment for copies is not included, this tax 
                                information disclosure authorization will be returned.

                                                     For LDR Use Only
                                Received by
                                Name                            Division
                                                                                                                         6501
                                Telephone   (      )            Date

R-7004i (12/16)
                                                              General Information
Purpose of Form—Use Form R-7004 to request one or more copies of a tax return, or to authorize  an individual, corporation, firm, organization, or 
partnership to receive your confidential information for the type of tax and for the years or periods that you list on the form. The authorization is only 
effective for disclosure of the specific tax matters listed in Section 3.
This form only authorizes the one-time release of information to your appointee. It does not provide for the continuous release of information to your 
appointee or authorize your appointee to advocate your position with respect to the state tax laws; to execute waivers, consents, or settlement agreements; 
or to otherwise represent you before the Louisiana Department of Revenue. If you want to authorize an individual to represent you on an ongoing basis 
in matters regarding state tax law, use Form R-7006, Power of Attorney.
Where to  file. Mail  your Tax  Information Disclosure Authorization  Form R-7004  and payment,  if applicable,  to the attention  of the LDR  division  or 
employee handling your tax matter at P.O. Box 201, Baton Rouge, LA 70821. To ensure proper receipt, you may obtain the specific division and/or office 
location, or fax number from the employee assisting you.
What sections to complete?
If you are                                 Yourself                                     An Appointee
Requesting copies of returns to be sent to Sections 1, 3, 4 and 5 must be completed     Sections 1, 2, 3, 4 and 5 must be completed
Authorizing release of tax information     Not Applicable                               Sections 1, 2, 3, and 5 must be completed
                                                              Specific Instructions
1. Taxpayer Information
   Individual  — Enter your name, Social Security Number, and address in the space provided. Enter your spouse’s name and Social Security 
   Number if a joint return was filed.
   Corporations, partnerships, or associations — Enter the name, Louisiana Account Identification Number, Federal Employer Identification 
   Number, and business address.
   Trust   — Enter the name of the trust, the title and address of the trustee, and Louisiana Account Identification Number or Federal Employer 
   Identification Number.
   Estate — Enter the name of the taxpayer, the title and address of the decedent’s executor or personal representative, and the name of the estate. 
   The identification number for an estate includes both the Federal Employer Identification Number, if the estate has one, and the decedent’s Social 
   Security Number.
   All Others  — Enter the name, Louisiana Account Identification Number, Federal Employer Identification Number, and the address.
2. Appointee
   Enter the full name, address, and telephone number of the person to whom you authorize to receive your tax matters information.
3. Tax Matters
   List the type of tax, such as income tax, corporation income and franchise taxes, sales tax, severance tax, or excise tax, the tax form number, the 
   years or periods to be disclosed, and the specific tax matter. Enter “Not applicable” in any of the columns that do not apply.
   For example, to authorize disclosure of your 2011 individual income tax return, Form IT-540, list Income tax in column (a), Form IT-540 in column 
   (b), and 2011 in column (c). To authorize disclosure for your 2011, 2012, and 2013 tax years, list the years as 2011 through 2013 or 2011-2013 
   in column (c). If you list a year for taxes filed monthly, semi-monthly or quarterly, information for all periods in the year will be disclosed. General 
   references such as “all years,” “All periods,” or “All taxes.” will not be processed.
   In column (d), enter the specific information to be disclosed. Examples of column (d) information include lien information, a balance due amount, a 
   tax liability, or copy of return.
4. Fees
   Act 130 of the 2015 Regular Session of the Louisiana Legislature amended Revised Statute 47:1507 to provide for fees for  searching for tax 
   returns and other documents, authenticating records, and certifying copies of tax returns and other documents (see Louisiana Administrative Code 
   61:III.1701). As of July 17, 2015, the fees are as follows:
   $15.00 for a copy of any tax return or other document previously filed by the taxpayer, or authorized representative, for each year or tax period 
   requested, regardless of whether the requested return or document is located. 
   $25.00 for each certified copy of a return or other document requested. 
   All fees must be paid when you submit the Tax Information Disclosure Authorization, Form R-7004 by check or money order, made payable to 
   the Department of Revenue. 
5. Signature of Taxpayer(s) 
   Form R-7004 must be signed and dated by the taxpayer listed in Section 1.
   Individuals — The Taxpayer must sign and date the authorization. If disclosure pertains to joint returns, both husband and wife must sign.
   Corporations — Generally, Form R-7004 can be signed by: (1) an officer having legal authority to bind the corporation, (2) any person designated 
   by the board of directors or other governing body, or (3) any officer or employee on written request by any principal officer and attested to by the 
   secretary or other officer.
   Partnerships — Generally, Form R-7004 can be signed by any person who was a member of the partnership during any tax period covered by 
   the tax information disclosure authorization, Form R-7004.
   All others  — Generally, Form R-7004 can be signed by any person who has authority to execute any form with respect to the tax matters and 
   periods listed in Section 3.