Webster Parish                                                     

Sales & Use Tax Commission
1128 Homer Road ˜˜˜˜P.O. Box 357 ˜˜˜˜ Minden, LA 71058 ˜˜˜˜ Phone: (318) 377-8948 ˜˜˜˜Fax: (318) 377-4089

                    REQUEST FOR WAIVER OF PENALTIES FOR DELINQUENCY

Taxpayer                                                                                                                                      

Address                                                                                                                                       

Account #                                      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 47:1603 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. 47:1602 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.

Date                                           Signature                                                                 

                                                           (Official title if acting for a corporation)