Louisiana Installment Request for Individual Income

Installment Request for Individual Income	
Form R-19026
R-19026 (10/23)

Installment Request
for Individual Income

Louisiana Department of Revenue
Collection Division
P.O. Box 66658
Baton Rouge, LA 70896-6658
Telephone: (855) 307-3893
Email: [email protected]

Monthly installments are available to taxpayers who are unable to pay the full balance owed by the due date. INSTALLMENT AGREEMENTS
FOR INDIVIDUAL INCOME MUST BE A MINIMUM OF SIX (6) MONTHS. During the installment agreement period, you must submit equal
monthly payments of the total balance due.
How to request an installment agreement:
There are two ways to request an installment agreement as listed below. DO NOT SUBMIT THIS FORM WITH YOUR INDIVIDUAL INCOME
TAX RETURN.
1.	 Submit an electronic application at latap.revenue.louisiana.gov
2.	 Email completed pages 2 and 3 to: [email protected]
3.	 Mail completed pages 2 and 3 to:
Louisiana Department of Revenue (LDR)
Collection Division
P. O. Box 66658
Baton Rouge, LA 70896-6658
If the request is approved, LDR will send you a notice detailing the terms of your agreement.
Additional documentation:
After a review of your request, you may be contacted by the Collection Division to provide additional supporting documentation. Any missing or
incomplete information will cause the request to be denied. All information on the application will be verified.
Down payment for an installment agreement:
A down payment of 20 percent of the total amount due is required for approval of an installment agreement. Payments can be made electronically
at latap.revenue.louisiana.gov or mailed in with the application.
Fee for an installment agreement:
There is a non-refundable installment agreement fee of $105. The installment agreement fee cannot be paid in installments nor waived or applied
against any tax debt. However, if your Louisiana adjusted gross income reported on your most recently filed individual income tax return is less
than or equal to $25,000 you are not required to submit the fee. If required, the $105 fee must be submitted along with your down payment
electronically or by mail. Failure to submit the fee, if required, or down payment may result in denial of your request.
When to make installment payments:
If the installment agreement request is approved by LDR, you will be notified. However, you should make monthly payments even if you have
not yet received a response from LDR.
How to make installment payments:
The use of automatic bank debit for payment of the agreement is required. With the bank debit, payments will be withdrawn from your checking
or savings account on the date you specify. Failure to have sufficient funds in your account at the time of debit will result in an NSF fee being
added to the balance due and result in your agreement being cancelled. The application for automatic bank debit is on page 3 of this form.
Will I continue to receive bills?
The normal billing process will continue. Part of that process is the issuance of a “Notice of Intent”. Failure to make the scheduled monthly
payments will result in seizure of bank accounts and/or garnishment of your wages. Please ensure the last four digits of your social security
number are written on your check or money order.
An approved installment agreement WILL NOT PREVENT the garnishment of any refund you are due from the Internal Revenue Service or LDR.
To protect the State’s interest, a State Tax Lien may be filed if tax due is greater than $2,500 and/or if payments exceed 12 months in duration.
What if I miss an installment payment?
If any installment payment is not paid before the established payment date, you will be in default of your agreement and the total outstanding
balance is immediately due. At this point, all collection actions will be reactivated. You may contact LDR to request reinstatement of your
installment agreement at which time you will need to pay a mandatory $60 reinstatement installment fee or a new $105 installment fee if the
agreement has been cancelled for 90 days or longer. However, you will not be charged a fee if your Louisiana adjusted gross income on your
individual income return is less than or equal to $25,000.
What if I do not stay current with my state taxes and returns?
If you do not stay current in your tax obligations to the state, you will be in default of your agreement and the total outstanding balance is
immediately due. At this point, all collection actions will be reactivated. You may contact LDR to request reinstatement of your installment
agreement, at which time you will need to pay a mandatory $60 reinstatement installment fee or a new $105 installment fee if the agreement has
been cancelled for 90 days or longer. However, you will not be charged the installment agreement fee or the reinstatement fee if your Louisiana
adjusted gross income on your individual income return is less than or equal to $25,000.
Contact information:
If you have questions about an installment request, contact the Collection Division at (855) 307-3893. If your request is approved, you will need
to contact the Collection Division before making the final payment since penalty, interest and collection fees will accrue until the tax is paid in full.

I

R-19026 (10/23)

Louisiana Department of Revenue
Collection Division
P.O. Box 66658
Baton Rouge, LA 70896-6658
Telephone: (855) 307-3893
Email: [email protected]

Installment Request
for Individual Income

PLEASE PRINT OR TYPE
Full Name

Social Security Number

Home Phone

Current Address (number and street)

Cell Phone

Unit Type

Unit Number

City

State

ZIP

Employer

Date of Hire (mm/dd/yyyy)

Employer’s Address

Gross Weekly Wage

Spouse’s Name

Spouse’s Social Security Number

Spouse’s Employer

Date of Hire (mm/dd/yyyy)

Spouse’s Employer Address

Gross Weekly Wage

Name of Bank (Personal)

Bank Account Number

Bank Routing Number

Name of Bank (Business)

Bank Account Number

Bank Routing Number

Tax periods to be included:

Date you wish to make your monthly payments:

1. Total amount due

$

2. Amount of initial payment to be made with application. Multiply Line 1 by 20 percent (.20).

$

3. Balance to be paid over length of agreement. Subtract Line 2 from Line 1.

$

4. Monthly payments. Divide Line 3 by the number of months agreed. Months agreed upon: ___________

$

THIS AGREEMENT MUST BE A MINIMUM OF SIX (6) MONTHS.
By signing below, taxpayer acknowledges and agrees to the following statements:
I/we expressly waive the restrictions and delays prescribed in LA R.S. 47:1562 through 47:1565 and acknowledge that upon execution
of this agreement the liabilities identified herein shall become final and immediately collectible.
I/we acknowledge that an approved installment agreement will not prevent the garnishment of any refund due from the IRS or LDR.
I/we agree to timely file all returns and pay all taxes that become due and acknowledge that failure to do so will be considered a default
under this agreement.
Under penalties of perjury, I declare that I have examined the Request for Payment Arrangement form, including all
accompanying documents, and hereby affirm that to the best of my knowledge and belief, it is true, correct, and complete.
Your Signature

Date (mm/dd/yyyy)

Spouse’s Signature

Date (mm/dd/yyyy)

I

R-19026 (10/23)

Louisiana Department of Revenue
Collection Division
P.O. Box 66658
Baton Rouge, LA 70896-6658
Telephone: (855) 307-3893
Email: [email protected]

Installment Request
for Individual Income

Name

Social Security Number

Spouse Name

Social Security Number

Daytime Telephone Number

Name of your Financial Institution

Bank Routing Number

Bank Account Number

Bank Account Name

Start Date (mm/dd/yyyyy)

■ Checking 	

■ Savings

Debit Date (mm/dd/yyyyy)

Debit Amount

NOTE: PLEASE ATTACH A VOIDED CHECK.

Signature and Verification
Under penalties of perjury, I (we) declare that the information is to the best of my (our) knowledge and belief is true, correct, and complete. I agree to
participate in this Automatic Bank Draft Program.
I also authorize the financial institutions involved in processing the electronic payment of taxes to receive confidential information necessary to answer
inquiries and resolve issues related to the payment.
Your Signature

Date (mm/dd/yyyy)

Spouse’s Signature

Date (mm/dd/yyyy)