Tax Amnesty Application Form - 2003 Page 2
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1
2North Dakota Office of State Tax Commissioner
Tax Amnesty Application
page 2
D. Payment Details
Complete the appropriate boxes in columns 1, 2, and 3 that correspond to the type of tax liability for which you are requesting Tax Amnesty. For
a complete listing of tax types, refer to page 3. In column 3, please indicate the total amount that is included in the payment you have enclosed
with this Application.
2.
Amount paid if you are
1.
paying on an Assessment
Amount paid if you
or existing liability.
3.
are filing returns
(Attach most recent copy
Total amount
under Tax Amnesty.
of billing or Notice of
paid with this
Tax Types
(Attach returns.)
Determination.)
Application.
1. Individual Income Tax
1
1
1
2. Corporate Income Tax
2
2
2
3
3
3
3. Sales Tax
4
4
4
4. Use Tax
5. Withholding Tax
5
5
5
6. Other
6
6
6
7. Other
7
7
7
8. Other
8
8
8
Total Amount Enclosed with this Application
$
Need Assistance? If you need help computing your tax liability or want to make arrangements to pay an amount due on or
before Saturday January 31, 2004, call the Tax Department, Monday - Friday, 8:00 AM - 5:00 PM, at 701-328-2775.
E. Certification & Signatures
By signing the Tax Amnesty Application,
I agree to satisfy all of the requirements for Tax Amnesty, and I understand that if all requirements are not satisfied, my request for
amnesty will be denied and approval will be deemed revoked.
I understand that any return filed with the Tax Amnesty application is subject to audit in the same manner as any timely filed tax return.
I declare under N.D.C.C. § 12.1-11-02, which provides for a Class A misdemeanor for making a false statement in a governmental
matter, that this application, and any accompanying schedules and statements, has been examined by me and to the best of my knowledge
and belief is a true, correct, and complete application. Any Tax Amnesty granted may be revoked if it is determined that a false
statement was made.
I understand that if I am requesting Tax Amnesty for any assessments in formal protest or litigation, I waive any right to amend, appeal,
or file a claim for refund unless my tax liability is changed as the result of a federal audit.
I agree to comply with all state tax laws for any return or tax due after June 30, 2003.
Please sign and date this application in the space provided below.
Taxpayer Signature
Date
Spouse Signature
Date
(if applicable)
Tax Department use only
Mail to:
TAX AMNESTY PROGRAM
OFFICE OF STATE TAX COMMISSIONER
PO BOX 4090
BISMARCK, ND 58502-4090
Need more information or assistance?
Call the Office of State Tax Commissioner:
701-328-2775
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