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R-16019 (5/08) CR1
Application for Louisiana Revenue Account Number
P.O. Box 201 For office use only.
Baton Rouge, LA 70821-0201
(225) 219-7318
Date of application
1. A. Sales/ Use B. ■ Withholding F. ■ Other
■ Louisiana General Sales Tax C. ■ Vehicle Rental Excise _________________________
■ Statewide Hotel/Motel D. ■ Severance
■ Jefferson Parish Hotel/Motel E. Oil and Gas Classification _________________________
■ Orleans Parish Hotel/Motel ■ Taxpayer Only
■ Orleans Parish Restaurant ■ Producer Only _________________________
■ N.O. Airport Food Establishments ■ Producer/Taxpayer
■ Motor Vehicle Lessors/Rentors
2. Reason for applying A. ■ Started new business C. ■ Other (specify)
B. ■ Purchased ongoing business: Name of previous owner
3. Indicate the account number you use for each tax filed with the Louisiana Department of Revenue.
LA Corp. Tax Number None ■ LA Sales Tax Number None ■ LA Excise Taxes Number None ■
LA Withholding Tax Number None ■ LA Severance Tax Number None ■ LA Natural Resource Number None■
4. A. Legal name(s)
B. Trade name of business Telephone ( ) __________________
5. A. Business location address (NO P.O. Box or General Delivery)
B. City and state C. ZIP
6. A. Address for receiving tax forms and correspondence (If same location, write “same”.)
B. C. D. ( ) E. ■ Additional mailing
City and State ZIP Telephone address(es) attached
7. Type of organization: A. Individual■ B. ■ Partnership C. ■ Corporation D. ■ Governmental E. Nonprofit■ F. ■Other
8. U.S. NAICS Code 9. Federal Employer None ■
(required) ID Number
10. If sole owner (individual): Name SSN
Home address Telephone ( )
11. If corporation or partner- Name Title
ship: name, title, Social SSN
Security Number, home Address ( )
address, and telephone Telephone _________________
number of officers or Name Title
partners SSN
Address Telephone ( ) _________________
12. A. Louisiana Charter Number (if known) _________________________ B. State of incorporation (if not Louisiana) ___________________
13. Permits -Sellers of liquor, beer, or wine (wholesale or retail), must obtain a permit from the Office of Alcohol and Tobacco Control. A permit from
the Louisiana State Police Gaming Division must be obtained by sellers of lottery tickets or operators of video poker games. Indicate permit
number(s) that you currently hold.
A. Lottery Permit Number B. Expiration Month/Year _______________________________
Alcohol Permit Number Expiration Month/Year _______________________________
VPG Permit Number Expiration Month/Year ___________________________
Mo. Day Yr. Domestic Foreign Fiscal Month
14. A. Corporation Income/Franchise: Date charter filed with Louisiana Secretary of State B. C.
15. Sales or Use Tax: Date business begins sales operation sfrom this location
16. Withholding Tax: (See instructions.) Select filing frequency. ■ quarterly ■ monthly ■semi-monthly
17. Severance Tax: Select filing frequency. ■ quarterly ■ monthly 45-day■
18. Description of business: (required)
Signature of applicant Title
I affirm that the information given
on this application is true and
correct. Signature of preparer Date (mm/dd/yyyy)
1500
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