Form R-6122 "Rehabilitation of Historic Structures Tax Credit Schedule of Payments of $100,000 or Greater" - Louisiana

What Is Form R-6122?

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 June 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-6122 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-6122 "Rehabilitation of Historic Structures Tax Credit Schedule of Payments of $100,000 or Greater" - Louisiana

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R-6122 (6/18)
Taxpayer Compliance - Economic Development Unit
Rehabilitation of Historic Structures Tax Credit
P.O. Box 66362
Baton Rouge, LA 70896-6362
Schedule of Payments of $100,000 or Greater
Telephone: (225) 219-2270
Address of Property
SHPO Project Number
Name of Entity/Person Earning Credit
FEIN or SSN or LA Revenue Account Number
LA State
Other/ Local
SSN or LA Revenue
Total Amount
Payee Name
Address
FEIN
Contractor’s
License Number
Account Number
Paid
License Number
(Specify)
Grand Total for Page
If this schedule was prepared by a paid preparer, that person must also sign in the appropriate space below, complete the information in the “Paid preparer use only” box and enter his or her identi-
fication number in the space provided under the box. If the paid preparer has a PTIN, that must be entered in the space provided under the box, otherwise enter the FEIN or LDR account number. If
paid preparer represents a firm, the firm’s FEIN must be entered in the “Paid preparer use only” box. Failure of paid preparer to sign or provide an identification number will result in assessment on the
preparer of the unidentified preparer penalty. The penalty of $50 is for each occurrence of failing to sign or providing identification number.
Print/Type Preparer’s Name
Preparer’s Signature
Date
(mm/dd/yyyy)
PAID
Check
if Self-employed
PREPARER
Firm’s Name
Firm’s EIN
USE ONLY
Firm’s Address
Telephone
For office
use only.
PTIN, FEIN, or LDR Account Number of
Page _______ of _________
Prepaid Preparer
R-6122 (6/18)
Taxpayer Compliance - Economic Development Unit
Rehabilitation of Historic Structures Tax Credit
P.O. Box 66362
Baton Rouge, LA 70896-6362
Schedule of Payments of $100,000 or Greater
Telephone: (225) 219-2270
Address of Property
SHPO Project Number
Name of Entity/Person Earning Credit
FEIN or SSN or LA Revenue Account Number
LA State
Other/ Local
SSN or LA Revenue
Total Amount
Payee Name
Address
FEIN
Contractor’s
License Number
Account Number
Paid
License Number
(Specify)
Grand Total for Page
If this schedule was prepared by a paid preparer, that person must also sign in the appropriate space below, complete the information in the “Paid preparer use only” box and enter his or her identi-
fication number in the space provided under the box. If the paid preparer has a PTIN, that must be entered in the space provided under the box, otherwise enter the FEIN or LDR account number. If
paid preparer represents a firm, the firm’s FEIN must be entered in the “Paid preparer use only” box. Failure of paid preparer to sign or provide an identification number will result in assessment on the
preparer of the unidentified preparer penalty. The penalty of $50 is for each occurrence of failing to sign or providing identification number.
Print/Type Preparer’s Name
Preparer’s Signature
Date
(mm/dd/yyyy)
PAID
Check
if Self-employed
PREPARER
Firm’s Name
Firm’s EIN
USE ONLY
Firm’s Address
Telephone
For office
use only.
PTIN, FEIN, or LDR Account Number of
Page _______ of _________
Prepaid Preparer