Application period is September 1, 2021 - October 31, 2021.
Applications may not be submitted and will not be accepted prior or subsequent to the application period.
Incomplete applications will not be reviewed.
Please do not begin this application until you have all required information listed in the tax credit guidance. 

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* 1. Applicant Information

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* 2. Date of Birth (MM-DD-YYYY)

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* 3. Last 4-digits of Social Security Number

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* 4. Home Address

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* 5. Telephone Number (NNN-NNN-NNNN)

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* 6. Email Address

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* 7. Healthcare Professional Type
FP= Family Practice
GP = General Practice
IM = Internal Medicine
OB/GYN = Obstetrics/Gynecology

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* 8. Licensure Information

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* 9. Attach a copy of your current Louisiana medical license.  License must be in effect for the requested tax year. Must be saved as the format below.

PDF, JPG, JPEG file types only.
Choose File

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* 10. Select the tax year(s) you have received the Louisiana Small Town Health Professional Tax Credit.

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* 11. How did you hear about the Small Town Health Professional Tax Credit?

T