Form R-8352BF Fillable LDR Affidavit of Fraudulent Refund Deposit for a Business
(all forms fillable on Windows, Mac, Android tablets, and iPad using Adobe Reader XI)

(: 1) Unchecked (: 2) Unchecked (Must include seal) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) 1 I am first duly sworn and state I am: 2 I state that the Louisiana Department of Revenue refund deposit listed below was not authorized by me and was fraudulently 3 I state that I did not receive any part of the proceeds of this deposit directly or indirectly and that this affidavit is made voluntarily for 4 Do you know who fraudulently deposited the refund? 5 I understand this fraud is subject to investigation by local state and federal law enforcement agencies and that I may be required to 6 I understand making a false sworn statement is subject to federal and state statutes and may be punishable by fines and/or by Affidavit of Fraudulent Refund Deposit appeared on this day of 20 Authorized Signature Title Bank account where the refund was deposited Bank where the refund was deposited comply with a court order or subpoena to give testimony Contact Person Name Deposit amount Deposit date deposited as described below without my knowledge or authorization Email Address for a Business imprisonment LA Revenue Account Number Louisiana Department of Revenue Mailing Address Notice: The person alleging fraud must execute the affidavit in the presence of the Notary Public Print witness name Print witness name Print name of Notary and Notary Number R 8352BF (8/08) Signature of witness Signature of witness Notary State State of Parish/County of Taxpayer s Bank Taxpayer s Bank Account No Taxpayer s Name Telephone Number the purpose of establishing the fact that the deposit was made fraudulently without my knowledge or authorization Thus Sworn to and Subscribed Before Me Notary in the presence of the undersigned two witnesses who personally came and Yes If yes provide details