Ldr Form R 8453C – Fill Out and Use This PDF

Name of Corporation

LA. Revenue Account Number	Federal Employer Identiication Number (FEIN)
Street Address of Corporation	City	State	ZIP

Part 1 - Tax Return Information (whole dollars only)

1	Income & Franchise tax due (Form CIFT-620, Line 14)	1	.00
2	Less Refundable Credits (Form CIFT-620, add Lines 15 & 15A)	2	.00
3	Refund (Form CIFT-620, Line 18)	3	.00
4	Total amount due (Form CIFT-620, Line 25)	4	.00
5	Amount of payment remitted electronically	5	.00

Part II - Declaration of Officer (Sign only after Part I is completed.)

Under penalties of perjury, I declare that I am an officer of the above corporation and that the information that I have given my electronic return originator (ERO), transmitter, and/or intermediate service provider (ISP) and the amounts in Part 1 above agree with the amounts on the corresponding lines of the LA. 2009 Income/2010 Franchise tax return. To the best of my knowledge and belief, the corporation’s return is true, correct, and complete. I consent to my ERO, transmitter, and/or ISP sending the corporation’s return, this declaration, accompanying schedules, and statements to the LA. Department of Revenue. I also consent to the LA. Department of Revenue sending my ERO, transmitter, and/or ISP an acknowledgment of receipt of transmission and an indication of whether or not the corporation’s return is accepted, and, if rejected, the reason(s) for the rejection.

■I authorize a representative of the LA. Department of Revenue to discuss my return and attachments with my preparer.

Part III - Declaration of Electronic Return Originator (ERO) and Paid Preparer

I declare that I have reviewed the above corporation’s return and that the entries on LA8453-C are complete and correct to the best of my knowledge. If I am only a collector, I am not responsible for reviewing the return and only declare that this form accurately relects the data on the return. The corporate office will have signed this form before I submit the return. I will give the officer a copy of all forms and information to be iled with the LA. Department of Revenue, and have followed all other requirements in Pub. 3112, IRS E-ile Application and Participation, and Pub. 4163, Modernized E-File Information for Authorized IRS E-Providers. If I am also the Paid Preparer, under penalties of perjury I declare that I have examined the above corporation’s return and accompanying schedules and statements, and to the best of my knowledge and belief, they are true, correct, and complete. This Paid Preparer declaration is based on all information of which I have any knowledge.

ERO’s Use Only

ERO’S Signature	Date (mm/dd/yyyy)	■ Check if also		■ Check if	ERO’s SSN or PTIN
X		paid preparer		self-employed
Firm’s name (or yours if self-employed)					EIN
City			State	ZIP	Phone Number
					(	)
Paid Preparer’s Use only
Preparer’s Signature	Date (mm/dd/yyyy)	■ Check if		Preparer’s SSN or PTIN
X		self-employed
Firm’s name (or yours if self-employed)					EIN
City			State	ZIP	Phone Number
					(	)