Maine Tax Amnesty Application Form - September 1 - November 30, 2003
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2Maine Revenue Services
Tax Amnesty Application
September 1- November 30, 2003
PART 1
PLEASE TYPE OR PRINT INFORMATION REQUIRED.
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PART 2
BE SURE TO SIGN THIS FORM.
I certify that I have read the information in this form, and I am eligible for Tax Amnesty under the law. I also certify, under penalty
of perjury, that all statements are true, complete and correct to the best of my knowledge and belief. I also agree to forgo the
right to protest or pursue an administrative or judicial proceeding with regard to the tax periods contained in this
Amnesty application or to claim any refund of money paid under the Tax Amnesty Program.
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QUESTIONS?
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1-866-430-3161
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INSTRUCTIONS
Part 1 Type or print the taxpayer’s complete name(s). Use
Column B. Enter account information for each type of
current address. Please enter a telephone number where you
tax owed. Find the code for the appropriate account type in the
or a representative can be reached during business hours.
account type code table above Part 3. Use a separate line for
each account type and for each period. Enter the period
Part 2 Sign and date above after reading the statement in this
beginning and ending dates.
part. Mail the Amnesty Application to: Maine Revenue
Services, PO Box 9101, Augusta, Maine 04332-9101.
Column C. Tax: Enter amount of tax due.
Part 3 If you have not previously filed a return for the periods
Column D. Interest: For each tax period and tax listed,
in question, or you are filing an amended return, you must fill
choose the rate from the Amnesty Interest Table on page 2 of
out a tax return and submit it with your Amnesty Application and
instructions for the tax period indicated in Column A, and the
payment. Call 1-866-430-3161 for forms or download from
month the return was due. Multiply the tax (Column C) by the
interest rate from the table and enter the interest amount in Column
D. If the return was due before January 1993 or if the debt is
Column A. Type of return:
IFTA tax, call 1-866-430-3161 for the appropriate interest rate.
• Check Original Return if this is the first return filed for this period.
Column E. Totals: Add tax and interest (Columns C & D)
• Check Amended Return if this is an amended return to a
due under Maine Tax Amnesty. Enter in Column E. Add all of
previously filed return.
the entries in Column E and enter the total in the “Total amount
• Check Payment Only if Amnesty Application covers payment
due” box.
on a tax debt for which you have a bill from Maine Revenue
Part 4 Indicate method of payment. If you pay by credit card,
Services.
be sure to fill in the card number and expiration date. Make
check payable to Treasurer, State of Maine. Be sure to sign
your check.
Send this form along with full payment of the total amount due as indicated on the reverse side of this application to:
MAINE REVENUE SERVICES, PO BOX 9101, AUGUSTA, ME 04332-9101.
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