Form 3855 - Michigan Tax Amnesty - 2001
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1
2Michigan Department of Treasury
3855 (10-01)
Michigan Tax Amnesty
Issued under authority of P.A. 168 of 2001. Filing is voluntary.
However, amnesty will not be granted if this form is not filed.
Amnesty
1-866-410-0002
See instructions on Page 2.
Information:
PART 1
4
4
1. Taxpayer Name (First, Middle Initial, Last)
2. Social Security Number
FOR
4
4
3. Spouse's Name (First, Middle Initial, Last)
4. Social Security Number
INDIVIDUALS
ONLY
4
5. Mailing Address (No., Street, P.O. Box or Rural Route)
City
State
ZIP Code
4
4
6. Business Name (DBA)
7. Federal Employer Identification Number (FEIN)
FOR
8. Contact Person
9. Business Title
10. State Where Incorporated
BUSINESSES
4
ONLY
11. Mailing Address (No., Street, P.O. Box or Rural Route)
City
State
ZIP Code
PART 2
Taxable Period
C
X
Type
Assessment
Covered
Amount of
of Tax
Number
(MM/YYYY)
Tax Due
Interest
Total
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12.
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13.
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14.
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15.
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16.
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17.
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18.
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SUBTOTAL
4
20.
Check here if you have continued Part 2 on the
21.
Supplemental Schedule and enter schedule total here.............................................
4
22.
TOTAL AMOUNT ........
4
Check here if you qualify for and are
23.
4
24.
requesting an installment plan. (See
TOTAL AMOUNT PAID
instructions on page 2 to see if you qualify.)
WITH THIS FORM .......
PART 3
Signature (Taxpayer or Authorized Business Official)
Date
I declare under penalty of perjury that I am eligible
for amnesty under the conditions listed on the
back of this form and that the information on this
Taxpayer's Spouse's Signature
Date
form
and
any
accompanying
returns
and
schedules is, to the best of my knowledge, true,
correct and complete.
Michigan Tax Amnesty
Mail this form with your returns and payment to:
Tax Amnesty
Ends July 1, 2002
Michigan Department of Treasury
P.O. Box 30477
Lansing, Michigan 48909-7977
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