Form R-20128 Request for Waiver of Penalty for Delinquency

Late Payment Off Other Off Period(s) Request for Waiver of Penalties for Delinquency and/or Underpayment Signature Official Title (if acting for a corporation) UET Off Account Number 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): Louisiana Department of Revenue P O Box 201 Baton Rouge LA 70821 0201 paragraph request is hereby made that the penalties of $ incurred under the provisions of R S 47:1602 and or 47:118 be waived Please Print or Type Pursuant to the provisions of Louisiana Revised Statute 47:1603 and based on the causes described in the preceding R 20128 (3/06) Taxpayer Type of Penalty Delinquent Off 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