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(: 2) Unchecked
(Must include seal)
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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
