Louisiana Transferee's Tax Credit Information Disclosure Authorization

Transferee's Tax Credit Information Disclosure Authorization
Form R-6145
R-6145 (4/14)

Transferee’s Tax Credit
Information Disclosure
Authorization

This form only authorizes a one-time release of the form R-6135 to an appointee and must be attached to the Credit Utilization Form, R-6140, authorizing the transfer. A separate R-6145 must be completed by each transferee for each transfer.
This form cannot be used for any other information release.
PLEASE PRINT OR TYPE.
Taxpayer Information — Taxpayer must sign and date this form.
Name

Social Security Number

Address

LA Revenue Account Number

City

State

ZIP

Federal Employer ID Number

Daytime Telephone Number

Appointee
Name

Telephone Number

Address

Fax Number

City

State

ZIP

E-mail Address

Tax Matters
The appointee is authorized to receive the Form R-6135, Credit Registration Form, from the Louisiana Department of
Revenue for the transferable tax credit listed below:
Transfer Date

LDR State Certification Number

(mm/dd/yyyy)

Signature of Taxpayer
I certify that I have the authority to execute this form with respect to the tax matters above.
Signature

Print Name

X
Title

Date (mm/dd/yyyy)

If not signed and dated, the form R-6135 will be mailed to the Taxpayer.

Signature of Taxpayer
Form R-6145 must be signed and dated by the taxpayer listed in the Taxpayer Information section.
Individuals — The Taxpayer must sign and date the authorization.
Corporations — Generally, Form R-6145 can be signed by: (1) an officer having legal authority to bind the corporation, (2) any person designated by
the board of directors or other governing body, or (3) any officer or employee on written request by any principal officer and attested to by the secretary
or other officer.
Partnerships — Generally, Form R-6145 can be signed by any person who is a member of the partnership.
All others — Generally, Form R-6145 can be signed by any person who has authority to execute any form with respect to tax matters.