Form R-540v 01 - Individual Income Tax Electronic Filing Payment Voucher - 2002
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1State of Louisiana
R-540V 01
Department of Revenue
P.O. Box 201
Baton Rouge, LA 70821-0201
Individual Income Tax Electronic Filing Payment Voucher
Important notice
Tax preparers should provide this form to clients who file electronically if a payment is due with the return. Taxpayer
clients who owe additional Louisiana individual income tax for 2001 must complete the payment voucher at the bottom
of this page, detach and mail by May 15, 2002, in order to avoid the assessment of penalties and interest. The top
portion of this form should also be completed and retained by the taxpayer as a record of payment.
Do not send cash.
Complete and retain this portion as a record of payment.
Individual Income Tax Electronic Filing Payment Voucher
Name __________________________________________
In order as listed on tax return
Address ________________________________________
Your Social Security Number (1) ___________________
City, State, ZIP __________________________________
Your spouse's Social Security Number (2) ___________
Amount of payment ____________________________
Check number ________________________________
Date sent _____________________________________
Detach and submit the voucher below with your payment by May 15, 2002.
Individual Income Tax Electronic Filing Payment Voucher
R-540V 01
E
Name
Print in order as listed above.
Address
Your Social Security Number (1)
City, State, ZIP
Your spouse's Social Security Number (2)
AMOUNT
Mail date
ENCLOSED
Make payment to:
•
Louisiana Department of Revenue
Please include your Social Security
Number on your payment.
P. O. Box 201
For office use only.
Baton Rouge, LA 70821-0201
6222
Do not send cash.
6 2224
66 1
1 2 3 1 2001
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