Form R-1362 - Natural Disaster Claim For Refund Of State Sales Taxes Paid
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3R-1362 (8/16)
Return completed form to:
Natural Disaster Claim for Refund of State
Louisiana Department of Revenue
Sales Taxes Paid
P.O. Box 91138
Baton Rouge, LA 70821-9138
Must attach Forms R-1362S and R-1362D
PLEASE PRINT OR TYPE.
Claimant’s Name
Social Security Number
DOB
(mm/dd/yyyy)
Spouse’s Name
Spouse’s Social Security Number
DOB
(mm/dd/yyyy)
City
State
ZIP
■
Mailing Address
Check box to indicate address change
Resident of Louisiana Since
Telephone
(mm/yyyy)
(Daytime)
Location and Description of Destruction
Street Address
City
ZIP
(including apartment number)
Parish
Date of Disaster
Name or Description of Disaster
(mm/dd/yyyy)
Primary Cause of Destruction:
Type of Home:
Flood
Wind
Other_________________________
House
Apartment/Condo
Mobile Home
■
■
■
■
■
■
Area(s) of the home that received damage:
Total Number of Areas
that Received Damage
Kitchen
Living Room
Dining Room
Bedroom(s)
______
■
■
■
■
(how many rooms)
Breakfast Area
Den
Garage/Carport
Bathroom(s)
______
■
■
■
■
(how many rooms)
Patio
Outdoor Structure
Other ______________
■
■
■
1 Total amount of unreimbursed property loss from Form R-1362S, Line 3, Total Column.
$
2 Total amount of state sales tax requested to be refunded from Form R-1362S, Line 6, Total Column.
$
Certified Statement of Natural Disaster Refund Claim
The above individual, being duly sworn, deposes and says that the following statement is true and correct, that he is entitled to the refund
requested, and that he is not delinquent with the State of Louisiana in the payment of any state taxes.
The property described on the schedule was destroyed by a natural disaster in a “natural disaster area” so declared by the President
of the United States. I hereby certify:
• That the destroyed property was held for personal use at my residence, was not owned by a business, partnership, or corporation,
and was not otherwise used by any person for commercial purposes;
• That the property was movable, both at the time of its purchase and at the time of its destruction;
• That I paid the Louisiana state sales/use tax on my purchase of the destroyed property in the amounts now requested to be
refunded, and that the property was not acquired by gift, purchased outside the state, or otherwise without payment by me of the
Louisiana sales/use tax; and,
• That all expected and actual reimbursements from insurance and other sources have been included.
Natural disaster refund claims must be notarized to be processed. Filing or submitting false information or false representation
on this refund claim may result in jail time of 5 years and/or fines up to $5,000 under Revised Statute 14:133.
_____________________
_____________________, ________
SWORN TO AND SUBSCRIBED BEFORE ME THIS
day of
year
Claimant’s Signature
Claimant’s Name
(please print)
Spouse’s Signature
Spouse’s Name
(please print)
Signature of Paid Preparer
Paid Preparer Telephone Number
Paid Preparer Name if other than taxpayer
(please print)
(
)
Notary Signature
Notary Number
Notary Name
(please print)
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