Form 615 - Application For Voluntary Disclosure
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1
2
3Alaska Department of Revenue
615
Application for Voluntary Disclosure
Part I
Representative’s name
State agency involved
Department of Revenue - Tax Division
Representative’s mailing address
Mailing address
550 W 7th Ave Ste 500
City, State, Zip Code
City, State, ZIP Code
Anchorage, AK 99501-3555
Representative’s email address (optional)
Questions? Email
dor.tax.disclosure@alaska.gov
Representative’s daytime telephone
Representative’s fax
Telephone number
FAX number
907-269-6620
907-269-6644
Part II
Tax Type
Tax periods
Corporation Net Income Tax (AS.43.20)
Entity type
1. Has the entity ever filed an income tax return with the
Yes
No
Corporation
Department of Revenue?
S Corporation
2. Has the entity ever been the subject of an inquiry by the
Yes
No
Department of Revenue with respect to liability for any
Partnership
taxes?
LLC (limited liability company)
Part III
Part IV
Attach the following information as Exhibit 1
Attach the following information as Exhibit 2
• A description of the qualified business entity’s business activities
• A statement with your estimate of the
• A description of the qualified business entity’s business in Alaska
amount of taxes due by tax period. Show
• The facts giving rise to the offer to enter into a Voluntary Disclosure Agreement
the accompanying computations.
• Whether the DOR has contacted the entity, and if so, the nature of such contacts
• The settlement terms proposed by the company
• If the entity is a partnership or LLC, the number of corporate partners or members
Part V
I declare under penalty of perjury under the laws of the State of Alaska, that I am authorized by the unnamed entity to act as its agent in
negotiating a settlement under Alaska’s Voluntary Disclosure Program and that the information given above and in the attached Exhibit 1 and
Exhibit 2 is true and correct to the best of my knowledge and belief.
Signature
Person completing form (Print name)
Date
Mail to: Alaska Department of Revenue - Tax Division
550 W 7th Ave Ste 500 • Anchorage AK 99501-3566
Telephone 907-269-6620
Department use only
FAX 907-269-6644
Date received
Case #
dor.tax.disclosure@alaska.gov
615
Retain a copy for your records
Form 0405-615 rev 01/08 • page 1
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