R-20193-I-L (7/03)                        State of Louisiana
                                      Department of Revenue

                  Instructions for Authorization Agreement for 
                  Electronic Funds Transfer (EFT) of Tax Payment 

If this is a new application for this account and tax type, mark the block labeled “New Application.”
If you are notifying the Department of a change, mark the block labeled “Change Document.” On
a change document, you should complete the taxpayer name, account number, tax type, and the
items being changed only. Changes to the payment method must be submitted at least 60 days in
advance.

Section I

All information requested in this section must be completed regardless of the payment method
selected.

Taxpayer  name:   Please  enter  the  name  that  appears  on  your  account  with  the  Louisiana
Department of Revenue for the tax for which you are completing this application.

Revenue Account Number:       Please enter the account number assigned to you by the Louisiana
Department of Revenue for the tax for which you are completing this application. For oil or gas
severance  tax,  this  is  the  5-digit  producer/purchaser  code  assigned  by  the  Office  of
Conservation; for timber or mineral severance tax, this is the 5-digit number assigned by the
Department of Revenue; for all other taxes, this is the 10-digit account number assigned by the
Department of Revenue.

Federal Identification Number: If you have a Federal Identification Number, insert it in the space
provided.

Tax Type:   Enter both the tax type name and corresponding National Automated Clearinghouse
Association (NACHA) code, as follows:

Sales Tax                                             Excise Taxes
General Sales (R-1029)                    04101       Alcohol                          06401
Hotel/Motel Jefferson/Orleans (R-1029 DS) 04121       Beer Returns                     06301
NOEH Hotel Room Occupancy Tax (R-1325)    04131       Gasoline Dealer                  05101
Automobile Rental Excise Tax (R-1329)     04111       Gasoline Jobber                  05111
Statewide Hotel/Motel                     04141       Gasoline User                    05121
                                                      Hazardous Waste                  09001
Severance Tax                                         Inspection and Supervision       15001
Oil Severance                             08100       Special Fuels Decals             05221
Gas Severance                             08200       Special Fuels Supplier           05201
Mineral Severance                         08600       Special Fuels User               05211
Timber Severance                          08700       Tobacco Permits                  07321
                                                      Tobacco Returns                  07301
                                                      Transportation and Communication 15011
Other Taxes
Withholding                               01100
Corporation Income/Franchise              02200
Natural Gas Franchise Tax                 08220
Oilfield Restoration (oil)                08111
Oilfield Restoration (gas)                08211

Payment by EFT:
Mandatory/Voluntary: If you have been notified by the Department of Revenue that you are
required by law to remit payments for this tax type electronically, mark “Mandatory.” If you wish
to voluntarily remit electronically, mark “Voluntary.”

If you mark “Voluntary,” you must indicate a requested implementation tax period and an antic-
ipated date of first transmission. VOLUNTARY PAYERS MAY NOT BEGIN PAYING ELEC-
TRONICALLY UNTIL THEY HAVE BEEN NOTIFIED BY THIS DEPARTMENT OF AN OFFI-
CIAL EFFECTIVE TAX PERIOD.         Electronic payments are restricted to those taxes listed on
the previous page. Taxpayers who voluntarily remit electronically must do so for a minimum of
one year and must comply with all EFT regulations.

Contact Person: Please list two contact persons for electronic funds transfer purposes and their
telephone numbers.

Mailing Address: Please indicate the address to which all information relative to electronic funds
transfers should be mailed.

SECTIONS II, III, AND IV

You must select only ONE method of payment: Automated Clearinghouse (ACH) Debit, ACH
Credit, or Other Immediately Investible Funds.

If you select the ACH Debit method, you must provide all information requested in Section II. The
transit and routing number is the series of digits on the lower left side of your check prior to your
account number. Be sure to attach a copy of a voided check.

If you select the ACH Credit with Addenda method, payments must be in the NACHA CCD+ for-
mat using the Tax Payment Convention (TXP). Check with your financial institution to be sure it
can accommodate your needs before selecting this method.

If you choose to pay by Other Immediately Investible Funds, please note that this includes cash,
money orders, and cashier’s checks, and that the payment must be delivered in person or by couri-
er to the Louisiana Department of Revenue on or before the due date of the return.

For assistance call:

Taxpayer Services Division                            (225) 219-7318
Corporation Income and Franchise Taxes                (225) 219-0067
Excise Taxes                                          (225) 219-7656
Sales Tax                                             (225) 219-7356
Withholding Tax                                       (225) 219-0102

Severance Tax Division                                (225) 219-2500