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Uisiana Department of Revenue P. O. Box 201 Baton Rouge, LA 70821-0201 (225) 219-7656 (225) 219-2114 (TDD) City, State, ZIP: Field flag Filing Period has O If your address circle. changed, mark TAXPAYER Taxpayer Account ID: ACCOUNT ID DISTRIBUTOR/EXPORTER/ BLENDER MONTHLY RETURN FOR OFFICE USE ONLY. If your name has changed, mark circle. DEB FEIN MM/YY Tax Computation A B (Complete Page 2, Lines 14 through 35 first.) Gasohol Gasolin.

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