R-541V (1/17) 

                         Fiduciary 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 fiduciary income tax for 2016 must complete the payment voucher at the bottom of this page, 
detach the voucher, and mail it with payment 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/latap

LDR Account Number       FEIN                                Tax Period

Name of Estate or Trust                                      Name of Fiduciary or Trustee

Address

City                                                         State      ZIP

Amount of payment        Check Number                                   Date Sent
$                       .

                        Detach and submit the voucher below with your payment by May 15, 2017.

R-541V (1/17)                                                                                             16 FI
                        Fiduciary Income Tax Electronic Filing Payment Voucher
LDR Account Number       FEIN                                Tax Period

Name of Estate or Trust                                      Name of Fiduciary or Trustee

Address

City                                                         State      ZIP

SPEC                     Make payment to:                    Amount 
CODE                     Louisiana Department of Revenue     enclosed u $
                         P. O. Box 3550                                                                   .
                         Baton Rouge, LA 70821-3550          DO NOT SEND CASH.
                         Please include your LDR Account     Mail date
                         Number on your payment.                                                          1903

                                                             For office use only
       19034             691  12312016