F-013 (7/15)                                                                                                     calstx 
  
                                         PARISH OF CALCASIEU 
                      SALES & USE TAX DEPARTMENT 
                                         P.O. Drawer 2050 
                                         Lake Charles, LA  70602-2050 
                                        337-217-4280   FAX 337-217-4281 
                                                       
                REQUEST FOR WAIVER OF PENALTIES FOR DELINQUENCY 
                                                       
 Taxpayer             
  
 Account Number   
  
 Tax 
  
 Period(s)        
  
 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 causes described in the 
 preceding paragraph, request is hereby made that the penalties of $              _________  incurred under the 
 provision 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                                                                                                                     
                                                                   (OFFICIAL TITLE IF ACTING FOR A CORPORATION) 
  
FOR OFFICE USE ONLY:                      
                                           Request:    ______Granted              ______Denied   
 
If denied, give reason:_____________________________________________________________________________ 
 
 Date: ________________________________   Signed: ______________________________________________ 
                                                                      Sales and Use Tax Department