STATE OF LOUISIANA ____________
PARISH OF _____________________
APPLICATION FOR POSTPONEMENT OF AD VALOREM TAXES
BEFORE ME, the undersigned authority personally appeared__________, a tax debtor, who requests postponement of payment of ad valorem taxes pursuant to the provisions of R.S. 47:2106 for the following property:
________________________________________________________________
(Give the description of damaged or destroyed property as assessed)
Appearer certifies that the property was damaged or destroyed on ______ (insert date)by the event that necessitated the emergency declaration declared on or about ______ (insert date) by __________ (insert name and title of person declaring the emergency) and it is in the geographical area designated in the declaration.
Appearer certifies that the collection of the taxes that became due after the declaration of emergency would be onerous because Appearer is unable to pay the taxes without suffering substantial hardship. Appearer submits his financial statement in support of this application and certifies that it is true and correct as of this date.
SWORN TO AND SUBSCRIBED BEFORE ME this ___ day of _____, _____ at __________ Louisiana.
________________
Full Name of Affiant
__________________________________
Notary Public or authorized tax collector
Notary #
FINANCIAL STATEMENT
STATE OF LOUISIANA
PARISH OF _____________
I certify that the following is a listing of my debts and property located within the state of Louisiana and that the following was my adjusted gross income for the previous year.
Immovable Property:
Estimated Value
(land/buildings)
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
Subtotal __________
Debts affecting the
Estimated Value
immovable property: ___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
Subtotal __________
Movable Property:
Estimated Value
(vehicles, personal
___________________________________________________
property, bank accounts) ___________________________________________________
___________________________________________________
___________________________________________________
Subtotal __________
Debts affecting the
Estimated Value
movable property:
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
Subtotal __________
Other Debts:
Estimated Value
(credit cards, etc.)
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
Subtotal __________
NET WORTH __________________
(Value of Property less amount of debts)
Adjusted gross income for
Previous year:
________________________
Applicant
Sworn to and signed before the undersigned Notary Public at ________________, Louisiana, on the _____ day of __________, _______.
________________________
Notary Public or authorized tax collector
Notary #
La. Revenue and Taxation § 47:2130