Affidavit Template - Alabama Department Of Revenue
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4C: 41E (2/00) — PAGE 1
A
D
R
OFFICE USE ONLY
LABAMA
EPARTMENT OF
EVENUE
Case No. ___________________
C
S
D
OLLECTION
ERVICES
IVISION
GR:
Yes
No
Affidavit
Under penalties of perjury, I declare that I have examined the information given in this
financial statement and, to the best of my knowledge and belief, it is true, correct, and
complete. I further declare that I have no assets, owned either directly or indirectly, or
income of any nature other than as shown in this statement. I agree to give written notice to
________
the Alabama Department of Revenue of any material changes in this information.
INITIAL
I understand that my failure to maintain current tax liabilities will void any payment
________
agreement.
INITIAL
I also understand that my failure to list all assets and document expenditures will void any
________
payment agreement.
INITIAL
I am proposing to send $_________________ per month, since I do not have available at this
________
time financial sources to pay this liability in full.
INITIAL
I understand that an installment payment agreement, if approved, may be considered as a
________
balloon note with the balance payable in full at the end of the agreement period.
INITIAL
INCOMPLETE / INACCURATE FORMS WILL NOT BE PROCESSED
TAXPAYER’S SIGNATURE
SPOUSE’S SIGNATURE
DATE
DATE
All forms must be signed and include all proofs/documents required.
Return the collection information packet to:
Alabama Department of Revenue
Collection Services Division
P.O. Box 327820
Montgomery, AL 36132-7820
Telephone: (334) 242-1220
Fax: (334) 242-8342
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