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Get LA LDR R-1362 2019

Lse information or false representation on this refund claim may result in jail time of 5 years and/or fines up to $5,000 under Louisiana Revised Statute 14:133. SWORN TO AND SUBSCRIBED BEFORE ME THIS day of , year Claimant s Name (please print) Claimant s Signature Spouse s Name (please print) Spouse s Signature Paid Preparer Name if other than taxpayer (please print) Signature of Paid Preparer Paid Preparer Telepho.

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