Form Fr-128 - Extension Of Time To File D.c. Franchise Or Partnership Return

Form Fr-128 - Extension Of Time To File D.c. Franchise Or Partnership Return - 2011 Page 2

*011280320000*

TAXPAYER NAME :

FEDERAL EMPLOYER I.D. NUMBER :

*011280320000*

Under penalties of law, including criminal penalties for false statements and tax preparer penalties under D.C. Code secs. 22-2514

and 47-161, et seq., I declare that I have examined this return and, to the best of my knowledge, it is correct. If prepared by a person

PLEASE

other than the taxpayer, this declaration is based on all information available to the preparer.

SIGN

HERE

Telephone Number of Person to Contact

CORPORATE

TAXPAYER(S) SIGNATURE(S) (See Instructions)

TITLE

DATE

SEAL

Preparer’s SSN or PTIN

DATE

PREPARER’S SIGNATURE (If other than taxpayer)

PAID

PREPARER

ONLY

Preparer’s Federal Employer I.D. Number

FIRM NAME

FIRM ADDRESS

Mail return and payment to: Government of the District of Columbia, Office of Tax and Revenue, 6

Floor, 941 North Capitol St., N.E. Washing-

ton, D.C. 20002. Make check or money order payable to the D.C. Treasurer. Include your Federal Employer ID number (or SSN), “FR-128” and

tax year on your payment.

Form Fr-128 - Extension Of Time To File D.c. Franchise Or Partnership Return - 2011 Page 2