Proud member of LATA 
                                  
  Ascension Parish Sales and Use Tax Authority 
                                 P.O. Box 1718 
                                Gonzales, LA  70707 
                                  
   REQUEST FOR WAIVER OF PENALTIES FOR DELINQUENCY 
                                  
Taxpayer ______________________________________________________________________________ 
Account number ________________________________________________________________________ 
Tax __________________________________________________________________________________ 
Period(s) ______________________________________________________________________________ 
Type of Penalty _____________ Delinquent _____________ Late Payment 
 
I hereby assert that the delinquency in filing the subject return and/or paying the subject tax was not due to 
my intent to violate the law, but was due to the following reason(s): 
 
Pursuant to the provisions of Louisiana Revised Statute 47:337.71 and based on the causes described in the 
preceding paragraph, request is hereby made that the penalties of $________________________________ 
incurred under the provisions of R. S.47:337.70 be waived.   
 
Under the penalty of perjury, I declare all of the facts alleged above as a basis for reasonable cause, to the 
best of my knowledge and belief, including all accompanying documentation, are true, correct, and complete. 
 
                                 Signature                               
Date ________/_______/_________  ___________________________________ 
                                 ___________________________________ 
                                 (OFFICAL TITLE IF ACTING FOR A CORPORATION)