Form R-1040 "Quality Jobs Income Tax Payroll Rebate Claim" - Louisiana

What Is Form R-1040?

This is a legal form that was released by the Louisiana Department of Revenue - a government authority operating within Louisiana. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2016;
  • The latest edition provided by the Louisiana Department of Revenue;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form R-1040 by clicking the link below or browse more documents and templates provided by the Louisiana Department of Revenue.

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Download Form R-1040 "Quality Jobs Income Tax Payroll Rebate Claim" - Louisiana

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R-1040 (1/16)
Mail to:
Louisiana Department of Revenue
Taxpayer Compliance Division-SSEW
Quality Jobs
Economic Development Unit
Income Tax Payroll Rebate Claim
P.O. Box 66362
Baton Rouge, LA 70896-6362
Phone: 225.219.2270
Email:
LDR.TaxIncentives@LA.gov
PLEASE PRINT OR TYPE.
Date of Claim
(mm/dd/yyyy)
LA Revenue Account Number
Quality Jobs Contract No.
Legal Name of Business
Trade Name of Business
Mailing Address
Project Location Address
City
State
ZIP
City
State
ZIP
Effective Date of Contract or Renewal
Date Affidavit of Annual Certification was certified
(mm/dd/yyyy)
(mm/dd/yyyy)
Rebate for Tax Year Ending ....................................................................................................
Payroll ......................................................................................................................................
%
Benefit Rate .............................................................................................................................
Rebate Earned .........................................................................................................................
DECLARATION
I declare that to the best of my knowledge of all available information, this rebate claim is true and complete and complies with all
statutes, rules and regulations, and any other policy pronouncements related to the Quality Jobs program.
Signature of Officer, Owner or Other (for Other, attach Power of Attorney):
Date
(mm/dd/yyyy)
Name
Title
Telephone Number
Email Address
QJ
R-1040 (1/16)
Mail to:
Louisiana Department of Revenue
Taxpayer Compliance Division-SSEW
Quality Jobs
Economic Development Unit
Income Tax Payroll Rebate Claim
P.O. Box 66362
Baton Rouge, LA 70896-6362
Phone: 225.219.2270
Email:
LDR.TaxIncentives@LA.gov
PLEASE PRINT OR TYPE.
Date of Claim
(mm/dd/yyyy)
LA Revenue Account Number
Quality Jobs Contract No.
Legal Name of Business
Trade Name of Business
Mailing Address
Project Location Address
City
State
ZIP
City
State
ZIP
Effective Date of Contract or Renewal
Date Affidavit of Annual Certification was certified
(mm/dd/yyyy)
(mm/dd/yyyy)
Rebate for Tax Year Ending ....................................................................................................
Payroll ......................................................................................................................................
%
Benefit Rate .............................................................................................................................
Rebate Earned .........................................................................................................................
DECLARATION
I declare that to the best of my knowledge of all available information, this rebate claim is true and complete and complies with all
statutes, rules and regulations, and any other policy pronouncements related to the Quality Jobs program.
Signature of Officer, Owner or Other (for Other, attach Power of Attorney):
Date
(mm/dd/yyyy)
Name
Title
Telephone Number
Email Address
QJ