Form 0405-021 - Assignment Of Rights Of Shared Tax Or Fee Payment
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021
Assignment of Rights of Shared Tax or Fee Payment
Assignments must be received by the due date to be accepted. Please read the instructions when completing this form.
ASSIGNOR (Local Government)
Maximum Amount to be Assigned
Local Government Name
Phone Number
Mailing Address
State
Zip + 4
Fax Number
City
ASSIGNEE (Payment to be assigned to)
Division
State Agency
Phone Number
Mailing Address
State
Zip + 4
Fax Number
City
Reason for Assignment:
This assignment relates to payment of shared taxes or fees payable to the
assignee above for fiscal year _____________from (check one).
Due Date
June 30
Aviation Motor Fuel Tax
December 31
Commercial Passenger Vessel Excise Tax
June 30
Electric/Telephone Cooperative Tax
June 30
Fisheries Business Tax
June 30
Fishery Resource Landing Tax
June 30 and December 31
Liquor License Fees
Assignor’s Signature Required. This assignment must be signed in the presence of a notary public.
I am authorized to assign payment on behalf of the local government (Assignor) named above and hereby assign to the agency
named (Assignee), rights to the payment for shared taxes or fees for the program indicated above.
Date
Assignor’s Signature
Position Held with Local Government
Assignor’s Name (printed)
Notary Public
Mail to: ALASKA DEPT OF REVENUE
This assignment was subscribed and sworn
TAX DIVISION
to before me on this _______ day of
PO BOX 110420
JUNEAU AK 99811-0420
_____________________________,
at ___________________________.
DEPARTMENT USE ONLY
_______________________________
Signature of Notary
021
________________
My commission expires:
0405-021 New 01/11
Please keep a copy for your records
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Parent category: Financial