Form 70-108-04-1-1-000 - Tax Amnesty Application 2004

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Mississippi
Form 70-108-04-1-1-000
For Office Use Only
Tax Amnesty Application
Route to the
Office of Revenue
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Mississippi has established a Tax Amnesty Program beginning September 1, 2004 and ending December 31, 2004. Penalties will be waived, and
possibly interest, for a taxpayer who applies for amnesty during the amnesty period and pays the full amount of all taxes due to the State Tax Commission
from January 1, 1999 and after.
SECTION 1: Type or Print Name, Mailing Address and Tax Identification Number.
Taxpayer Name
Spouse Name
Legal Business Name
Mailing Address
Street Address or P.O. Box
ZIP
City
State
County
Phone Number
Taxpayer's Social Security Number
(
)
E-mail Address
Spouse's Social Security Number
Fax Number
Federal Employer's Identification Number
(
)
SECTION 2: Indicate Type Tax For Which You Are Requesting Amnesty, Tax Period and Amount Due For Each.
ENTER TAX PERIOD
TYPE RETURN
ACCOUNT NUMBER or
TYPE OF TAX
SOCIAL SECURITY
ENTER AMOUNT DUE
ORIGINAL
AMENDED
BEGINNING
ENDING
NUMBER
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TOTAL AMOUNT DUE
Are you requesting interest being waived as well as penalty?
YES
NO
Have you collected the tax for which you are requesting AMNESTY?
YES
NO
If YES, please explain why you feel interest should
be waived.
SECTION 3: Sign this Application.
I certify that I am eligible for amnesty under the conditions outlined on the back of this application, and that the information on this application,
accompanying returns and schedules is to the best of my knowledge, true, correct and complete.
Taxpayer or
Date
Spouse Signature
Date
Authorized STC Official
Date

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