Form R-1021 - Sales Tax Electronic Filing Payment Voucher
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R-1021 (1/07)
Sales Tax Electronic Filing
Payment Voucher
Louisiana Department of Revenue
Sales Tax Division
P.O. Box 3138
Baton Rouge, LA 70821-3138
Important notice
The coupon below must be used as a remittance advice by those sales tax filers who have submitted their sales tax returns through
on-line electronic filing, and who are not required or who have not elected to submit their remittances through electronic funds transfer.
In order to avoid the assessment of penalties and interest, remittance of the full amount due on the electronically filed return must be
submitted to the Department on or before the 20 th day of the month following the close of the calendar month covered by the return.
Please assure that your sales tax account number and the filing period are correctly shown in the spaces provided on the coupon. Please
complete and retain the top portion of this form as a record of your payment.
{Complete and retain this portion as a record of payment.}
PLEASE PRINT OR TYPE.
Name
Account number
Address
Filing period (MM/YY)
City
State
ZIP
DO NOT SEND CASH.
Amount of payment
Check number
Date sent
Detach and submit the voucher below with your payment by the 20 th of the month following the month of the return.
Sales Tax Electronic Filing Payment Voucher
R-1021 (1/07)
Name
Account number
S
Address
Filing period (MM/YY)
City
State
ZIP
Make payment to
AMOUNT
DO NOT SEND CASH.
ENCLOSED
Louisiana Department of Revenue
P.O. Box 3138
Baton Rouge, LA 70821-3138
FOR OFFICE USE ONLY.
Mail date
1903
19034
4358485649
443
12312006 00000000 4376538544 00000500009 9
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