R-20130 (1/08)

                                       Request for Compromise of Interest

                           Louisiana Department of Revenue
                           P. O. Box 66658
                           Baton Rouge, LA  70896-6658

                                                                                                     PLEASE PRINT OR TYPE.
Taxpayer Name                                                                    Louisiana Revenue Account ID Number

Tax Type                                    Tax Period(s)                        Amount of Interest to be compromised

According to Louisiana Revised Statute 47:1601(A)(2)(d), and subject to the conditions of Louisiana Administrative Code 61:III.2115.B, a 
request may be made to compromise the amount of interest to be added to the amount of tax due. A request for compromise will NOT be 
considered if any of the following apply:
 • All outstanding taxes have not been paid.
 • There is a binding judicial decision regarding the issue.
 • The taxpayer has had any interest compromised in the last five years.
 • The taxpayer, his affiliates or related entities have had interest compromised for the same issue.
 • The taxpayer is party to a voluntary disclosure agreement for the same period.
 • The interest accrued as a result of participation in an abusive tax avoidance transaction.
 • The interest accrued on taxes that were collected on behalf of the state but not remitted.

A complete record of all amounts compromised shall be maintained by the secretary, shall be open to public inspection, and shall be 
published in the Department’s annual report.

Request is hereby made to compromise the amount of interest based on the following reasons:

Under penalty of perjury, I declare all of the facts provided above as a basis for a compromise, to the best of my knowledge and belief, 
including all accompanying documentation, are true, correct, and complete.
Taxpayer’s Authorized Representative                        Title

Signature of Authorized Representative                      Date (mm/dd/yyyy)

                                            FOR OFFICIAL USE ONLY
                                                            Amount of Interest Compromised
         ■  Approved                   ■  Disapproved

Department Representative                                   Approval Date