Form R-7004 "Tax Information Disclosure Authorization" - Louisiana

What Is Form R-7004?

This is a legal form that was released by the Louisiana Department of Revenue - a government authority operating within Louisiana. Check the official instructions before completing and submitting the form.

Form Details:

  • Released on July 1, 2018;
  • 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;

Download a fillable version of Form R-7004 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-7004 "Tax Information Disclosure Authorization" - Louisiana

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R-7004 (7/18)
Louisiana Department of Revenue
Tax Information Disclosure Authorization
P.O. Box 201
Baton Rouge, LA 70821
1. Taxpayer Information — Taxpayer must sign and date this form.
Name
Social Security Number
Spouse’s Name (if joint return)
Spouse’s Social Security Number
Address
LA Revenue Account Number
Federal Employer ID Number
City
State
ZIP
Daytime Telephone Number
2. Appointee — If you want to name more than one appointee, attach a list to this form.
Name
Telephone Number
Address
Fax Number
City
State
ZIP
The appointee is authorized to inspect and receive confidential tax information in any office of the
3. Tax Matters —
Louisiana Department of Revenue for the tax matters listed below.
A
B
C
D
Tax Type
Tax Form Number
Tax Year or Period
Specific Tax Matters
4. Fees
C
B
A
Total Fee Due (Multiply
Number of Tax Years or Period
Fee
Column A by Column B)
If you are requesting copies of
$15.00
returns listed above:
If you are requesting CERTIFIED
$25.00
copies of returns listed above:
Total Amount Due - Add amounts in Column C.
$
Make Payment To: Louisiana Department of Revenue. Do not send cash. PAY THIS AMOUNT.
5.
Signature of taxpayer(s). If a tax matter applies to a joint return, both spouses must sign.
I certify that I have the authority to execute this form with respect to the tax matters/periods in Section 3 above.
Signature
Signature
(Spouse)
Print Name
Print Name
(Spouse)
Title
Title
Date
Date
(mm/dd/yyyy)
(mm/dd/yyyy)
If not signed and dated and payment for copies is not included, this tax information disclosure authorization will be returned.
For LDR Use Only
Received by
Name
Division
6501
(
)
Telephone
Date
R-7004 (7/18)
Louisiana Department of Revenue
Tax Information Disclosure Authorization
P.O. Box 201
Baton Rouge, LA 70821
1. Taxpayer Information — Taxpayer must sign and date this form.
Name
Social Security Number
Spouse’s Name (if joint return)
Spouse’s Social Security Number
Address
LA Revenue Account Number
Federal Employer ID Number
City
State
ZIP
Daytime Telephone Number
2. Appointee — If you want to name more than one appointee, attach a list to this form.
Name
Telephone Number
Address
Fax Number
City
State
ZIP
The appointee is authorized to inspect and receive confidential tax information in any office of the
3. Tax Matters —
Louisiana Department of Revenue for the tax matters listed below.
A
B
C
D
Tax Type
Tax Form Number
Tax Year or Period
Specific Tax Matters
4. Fees
C
B
A
Total Fee Due (Multiply
Number of Tax Years or Period
Fee
Column A by Column B)
If you are requesting copies of
$15.00
returns listed above:
If you are requesting CERTIFIED
$25.00
copies of returns listed above:
Total Amount Due - Add amounts in Column C.
$
Make Payment To: Louisiana Department of Revenue. Do not send cash. PAY THIS AMOUNT.
5.
Signature of taxpayer(s). If a tax matter applies to a joint return, both spouses must sign.
I certify that I have the authority to execute this form with respect to the tax matters/periods in Section 3 above.
Signature
Signature
(Spouse)
Print Name
Print Name
(Spouse)
Title
Title
Date
Date
(mm/dd/yyyy)
(mm/dd/yyyy)
If not signed and dated and payment for copies is not included, this tax information disclosure authorization will be returned.
For LDR Use Only
Received by
Name
Division
6501
(
)
Telephone
Date