Request For Cigarette Tax Installment Agreement Form printable pdf download

Request For Cigarette Tax Installment Agreement Form

NEW YORK CITY DEPARTMENT OF FINANCE

ENFORCEMENT DIVISION

REQUEST FOR

CIGARETTE TAX INSTALLMENT AGREEMENT

Finance

Mail to: NYC Department of Finance, Enforcement Division, CTX Unit, 30-10 Starr Ave., 2nd Fl., Long Island City, NY 11101

Instructions: Please complete this form in its entirety and return to the address above within ten (10) business

days. You must include an initial payment of not less than 25% of your total liability.

If your request is denied: We will notify you in writing and the outstanding balance will be due immediately. If

your request is approved: You will be allowed to satisfy your outstanding liability in monthly installments as you

have indicated below. Generally, you can have up to 60 months to pay.

Since you will not be receiving any additional correspondence or bills from this office concerning this liability,

you will be responsible for ensuring that payments are made each month until the outstanding balance is paid

in full. Failure to make payments under the agreement may lead to collection measures, including the imposi-

tion of penalties.

CIGARETTE TAX TRACKING NUMBER:

SOCIAL SECURITY NUMBER:

DOF USE ONLY:

(SEE YOUR TAX PAYMENT FORM)

PRINT FIRST NAME:

PRINT LAST NAME:

DAYTIME PHONE NUMBER:

STREET # AND ADDRESS:

CITY:

STATE:

ZIP CODE:

TOTAL AMOUNT

NUMER OF MONTHLY

AMOUNT OF EACH

ANTICIPATED

OF TAX DUE:

PAYMENTS REQUESTED:

MONTHLY PAYMENT:

COMPLETION DATE:

$ $

REASON FOR REQUEST (EXPLAIN THE NATURE OF YOUR FINANCIAL HARDSHIP):

’

SIGNATURE

TODAY

S DATE

CigTaxInstallForm. 06.17.11

Request For Cigarette Tax Installment Agreement Form