Form 22-020a - Iowa Tax Amnesty Application - 2007

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Application
IOWA TAX
AMNESTY
Due Date: October 31, 2007
Part I: Reason for Requesting Tax Amnesty (check all that apply)
This application and attachments are
Return has not been filed. Attach completed return(s) to this application.
subject to Iowa Department of
Revenue review and approval. If the
Amended return being filed. Attach completed return(s) to this application.
Department calculates a different
Notice of tax due has been received but has not been paid in full.
amount due, you will be sent
Attach a copy of the notice to this application.
notification of the additional amount
Part II: Taxpayer Information (please print)
required to be paid for approval.
_____________________________
_________________
____
_________________________
Your Last Name
First Name
MI
Social Security Number
_____________________________
_________________
____
_________________________
Spouse (if applicable) Last Name
First Name
MI
Social Security Number
_____________________________________________
___________________________________
Business Name (if applicable)
Federal Identification Number (if applicable)
_____________________________________________
____________________
___________
___________
Street Address
City
State
Zip
_____________________________
____________________
________________________________________
Permit Number (if applicable)
County
Telephone Number(s)
________________________________________
E-mail Address
Part III: Tax Information (attach additional sheets if necessary)
Tax Type
Tax Period
Tax Amount
One-Half
Total
Ending Date
Due
Interest
Total Amount Due:
Part IV: Signature
I declare that I have examined this form and all accompanying returns and supporting information, and to the
best of my knowledge they are correct and complete. I understand that if I fail to meet all requirements for
Iowa Tax Amnesty, this application will be declared null and void. I understand that all payments will be
retained by the Department and applied to my outstanding liability and that I am relinquishing any further
appeal rights for the tax periods shown above.
_____________________________________________
_________________________________
Signature
Date
_____________________________________________
_________________________________
Spouse Signature (if applicable)
Date
_____________________________________________
Title (if application is for a business or organization)
22-020a (7/19/07)

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