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2011

Form M-4868

Massachusetts

Application for Automatic Six-Month Extension

Department of

of Time to File Massachusetts Income Tax Return

Revenue

For the year January 1–December 31, 2011 or other taxable year beginning

ending

Tentative Return

1 Total tax you expect to owe for 2011 (Form 1, lines 28 and 33 (if applicable); Form 1-NR/PY, lines 32 and 38 (if applicable) . . . . 1

2 Massachusetts income tax withheld . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

3 2010 overpayment applied to your 2011 estimated tax (do not enter 2010 refund) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

4 2011 Massachusetts estimated tax payments (do not include amount in line 3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

5 Credits (see Form 1, lines 29, 30 and 40 through 42; Form 1-NR/PY, lines 33 through 35 and 45 through 47) . . . . . . . . . . . . . . . 5

6 Total. Add lines 2 through 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

7 Amount due. Subtract line 6 from line 1; not less than “0.” Pay in full with this application. Note: If “0,” see below for

information regarding automatic extensions. Payments of $5,000 or more must be made electronically. If you are

making a payment of less than $5,000, you also have the option of filing Form M-4868 electronically. See below for

more information. Be sure to detach Form M-4868 where indicated before mailing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 7

Automatic Extension Granted if 100% Tax Due is Paid by Tax Return Due Date

If line 7 is “0” and 100% of the tax due for 2011 has been paid through: withholding; timely estimated payments of tax; credits from your

2011 return; or a refund from the prior tax year applied to the current year’s tax liability, you are no longer required to file Form M-4868,

Application for Automatic Extension of Time to File Massachusetts Income Tax Return. However, if you do choose to file Form M-4868

in this instance, you must do so electronically, via DOR’s website. See

TIR 06-21

for more information.

Filing Your Extension Via the Web

If you owe no tax or you are making a payment of $5,000 or more, you are required to file your extension via the Web. If you are making

a payment of less than $5,000, you also have the option of filing your extension electronically. If there is a tax due with your extension,

payment can be made through Electronic Funds Withdrawal.

Visit to file via the Web or to obtain Form M-4868.

Note: Instructions for Form M-4868 are on page 2.

DETACH HERE (if making a payment)

Massachusetts

Form M-4868

Application for Automatic Six-Month Extension — 2011

Department of Revenue

Social Security number

Spouse’s Social Security number

Period end date

Amount enclosed (from above)

Taxpayer’s name

Check which form you plan to file:

Form 1 Full-Year Resident

Form 1-NR/PY Nonresident/

Taxpayer’s address

City/Town

State

Zip

Part-Year Resident

E-File

Composite

Write your Social Security number(s) on lower left corner of check. Return this voucher with check or money order payable to:

Commonwealth of Massachusetts. Mail to: Massachusetts Department of Revenue, PO Box 7070, Boston, MA 02204.

Sign here. Under penalties of perjury, I declare that to the best of my knowledge and belief this return and enclosures are true, correct and complete.

Your signature

Signature of paid preparer

Date

Employer Identification number of paid preparer

Social Security number or PTIN

0140 104 1