R 19026 Form – Fill Out and Use This PDF

R-19026 (9/07)

Installment Request for Individual Income

THIS AGREEMENT CANNOT EXCEED SIX (6) MONTHS.

Note: Do not file this form if you are currently making payments on an installment agreement.

During the existence of this agreement, you must file all state tax returns and pay all state taxes timely.

Monthly installments are available to taxpayers who are unable to pay the full balance owed by the due date. During this period, you must submit monthly payments equal to 1/6 of the total balance due. When the payment plan request has been approved, you will be notified. You should make monthly payments even if you have not received a response from the Department.

An approved installment agreement will not prevent the assignment of your account for garnishment of any refund due from the Internal Revenue Service or the Louisiana Department of Revenue. To protect the StateÕs interest, a Tax Assessment and Lien may be filed.

First name	Middle initial	Last name	Social Security Number
SpouseÕs First Name	Middle initial	Last name	Social Security Number
Current address (number and street)			Apartment number
City	State	ZIP	Telephone Number

To apply for an installment agreement, do not submit this form with your return. Mail the form to:

Louisiana Department of Revenue

P. O. Box 66658

Baton Rouge, LA 70896-6658

Tax period(s) to be included: __________________

Date you wish to make your monthly payments: ________________

To calculate the amount of your monthly payment, divide the total amount due by six (6).

Total amount due $ ______________________ Ö 6 = $ ______________________ amount of monthly payment

We encourage the use of automatic bank debit for payment of the agreement. With the bank debit, payments will be withdrawn from your checking or savings account on the date you specify. Failure to have sufficient funds in your account at the time of debit will result in an NSF fee being added to the balance due and result in your agreement being cancelled. The application for automatic bank debit

is on the reverse side of this form.

If you have questions about an installment request, contact the Collection Division at (225) 219-7448. If your request is approved, you will need to contact the Collection Division to determine the amount of the final payment since penalty, interest and collection fees will accrue until the tax is paid in full.

The normal billing process will continue. A part of that process is the issuance of a ÒNotice of IntentÓ. Failure to make the scheduled

monthly payment will result in seizure of bank accounts and/or garnishment of your wages. Please ensure that your social

security number is written on your remittance.

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R-19026 (9/07)

Installment Request for Individual Income

This agreement cannot exceed six (6) months.

Bank Debit Application

Request must be mailed to: Louisiana Department of Revenue

Collection Division

Post Office Box 66658

Baton Rouge, La 70896-6658

Name___________________________________________ Social Security Number __________ - __________ - __________

Spouse Name_____________________________________ Social Security Number __________ - __________ - __________

Daytime Telephone Number

Name of your Financial Institution

Bank Routing Number

Bank Account Number

Bank Account Name _____________________

Checking ❏ Savings ❏

Start Date

Debit Date

Debit Amount

Signature and Verification

Under penalties of perjury, I (we) declare that the information is to the best of my (our) knowledge and belief is true, correct, and complete. I agree to participate in this Automatic Bank Draft Program.

I also authorize the financial institutions involved in processing the electronic payment of taxes to receive confidential information necessary to answer inquiries and resolve issues related to the payment.

Your signature___________________________________________________________	Date__________________
Spouse’s Signature________________________________________________________	Date___________________

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