Form Com/am-01 - Tax Amnesty Application And Supplement - Comptroller Of Maryland

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MARYLAND TAX AMNESTY APPLICATION

PART I – PLEASE TYPE OR PRINT INFORMATION REQUIRED

NAME

SOCIAL SECURITY NUMBER

SPOUSE’S NAME IF JOINT AMNESTY

SOCIAL SECURITY NUMBER

BUSINESS NAME (IF APPLICABLE)

CENTRAL REGISTRATION NUMBER OR FEIN NUMBER (IF APPLICABLE)

MAILING ADDRESS (NUMBER, STREET, UNIT, APT)

TELEPHONE NUMBER

CITY, TOWN OR POST OFFICE

COUNTY

STATE

ZIP CODE

Select or Enter County

PART II – TAXES ELIGIBLE FOR AMNESTY: Check one. You must file a separate Amnesty

application for each type of tax.

Personal Income Tax

Sales and Use Tax

Corporation Income Tax

Admissions and Amusement Tax

Employer Withholding Tax

Pass-through Entity Income Tax

Fiduciary Income Tax

PART III – INDICATE PERIODS FOR WHICH TAX IS OWED AND AMOUNTS OWED

TYPE OF RETURNS

INTEREST

ENTER TAX PERIOD

TAX

TOTALS

ATTACHED (IF APPLICABLE)

See instructions on back

MONTH/YEAR

ORIGINAL

AMENDED

AMOUNT OF

ADD COLUMNS

(BEGINNING)

(ENDING)

RETURN

TAX DUE

INTEREST DUE

C & D ACROSS

$0.00

Click here to use supplementary form (COM/AM-02),

SUBTOTAL

if additional lines are required

TOTALS FROM ADDITIONAL SHEET(S)

TOTAL

PAY THIS AMOUNT

P P P P P AR

ART T T T T IV

IV ENCLOSE OR INDICA

ENCLOSE OR INDICA

ENCLOSE OR INDICATE P

TE P

TE PA A A A A YMENT

YMENT

YMENT AND SIGN

AND SIGN

AND SIGN APPLICA

AND SIGN

APPLICA

APPLICATION

TION

Make checks or money orders payable to COMPTROLLER OF MARYLAND

Payment attached. Please attach all documents and payments with one staple. Write your Social Security number or FEIN on the payment.

Credit card payment.

Click here to make credit card payments

using American Express, Discover or MasterCard, or

see instructions

on back.

Enter confirmation number: __________________________________________

I certify that I have read the information on the back of this application and I am eligible for tax Amnesty under the law. I also certify that all Attachments and

statements are true, complete and correct to the best of my knowledge.

Signature of Taxpayer

Date

Signature of Agent/Preparer

Date

Signature of Spouse (if joint)

Date

Telephone number of Agent/Preparer

Check here

if you authorize your agent/preparer to discuss this information with the office of the Comptroller.

COM/AM-01