Request For Waiver Of Mandatory Electronic Payment Of Taxes Owed Form

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ADMINISTRATIVE & FINANCIAL SERVICES
STATE OF MAINE
RYAN LOW
MAINE REVENUE SERVICES
COMMISSIONER
24 STATE HOUSE STATION
AUGUSTA, MAINE
MAINE REVENUE SERVICES
04333-0024
JOHN ELIAS BALDACCI
JEROME D. GERARD
GOVERNOR
ACTING EXECUTIVE DIRECTOR
Contact Name:
Phone:
EIN/SSN: ______________ _
Company Name and Address:
To:
Maine Revenue Services
Subject:
Request for Waiver of Mandatory Electronic Payment of Taxes Owed
On behalf of the individual/entity listed above, a waiver from remitting tax payments electronically to the
State of Maine as mandated in Maine Revenue Service’s Rule 102 is hereby requested.
Reason for Request: (see Rule 102 mandate, sect 7)
a. The taxpayer's bank does not participate in ACH in any form.
b. Future trend analysis shows decline resulting in tax liability below threshold.
c. Liability during lookback period no longer meets/exceeds threshold
.
d. Liability meets/exceeds threshold due to uncharacteristic amounts in 3 or fewer months.
e. The taxpayer is under the payroll administration of the federal government.
f. The taxpayer is required to file three or fewer times per year.
g. Other:
* please include supporting information if applicable *
Date Expected to be in Compliance:
Requests may be submitted via email, in which case responses will also be returned by email.
----------------------------------------------- FOR MRS USE ONLY --------------------------------------------
Your request for a waiver has been::
Approved, through __________
Denied
Date Received:
Please contact me or Sally Sirois if you have any questions.
Matthew Pettengill
Staff Accountant
EFT/Deposit Unit
Tel. 207-287-2936/5395 Fax 207-287-6975 TTY 1-888-577-6690 E-Mail: efunds.transfer@maine.gov,

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