Form Tpg-169 - Individual Income Tax Status Letter Request - Department Of Revenue Services
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Department of Revenue Services
Individual Income Tax
Taxpayer Services Division
25 Sigourney St Ste 2
Status Letter Request
Hartford CT 06106-5032
(Letter of Good Standing)
TPG-169 (Rev. 08/09)
Part I: Taxpayer Information
Name
(Last, fi rst, MI)
Social Security Number
• •
• •
• •
• •
Spouse’s name (if joint request)
(Last, fi rst, MI)
Spouse’s Social Security Number
• •
• •
• •
• •
Mailing address
Telephone number (daytime)
(
)
City
State
ZIP code
Email address:
Part II: Status Letter Information
Year(s) for Request of Status Letter:
Reason for Request:
Part III: Third Party Information - The Department of Revenue Services (DRS) will send the original of any letter
to the person making the request and mail or fax a copy to a third party.
Check here if you wish to have the status letter mailed to a third party:
Name
Address
City
State
ZIP code
Check here if you wish to have the status letter faxed to a third party:
Name
Fax number
(
)
Part IV: Declaration
I declare under penalty of law that I have examined this document (including any accompanying schedules and
statements) and, to the best of my knowledge and belief, it is true, complete, and correct. I understand the penalty
for willfully delivering a false return or document to DRS is a fi ne of not more than $5,000, or imprisonment for not
more than fi ve years, or both. The declaration of a paid preparer other than the taxpayer is based on all information
of which the preparer has any knowledge.
Signature
Print name
Date
Sign here
and keep
a copy for
your
Spouse’s signature (if joint request)
Print name
Date
records.
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