Montana Form Ext-04 - Extension Payment Worksheet - 2004 Page 2
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1
2Attention
Montana Department of Revenue Cashier
Individual Extension Payment Form
Complete the payment form below to ensure proper credit of your payment.
Box 1, year ending date
Box 2, social security number
Box 3, amount paid
Name
Address
Phone
Mail this entire form with your check and return to:
Department of Revenue
PO Box 5805
Helena, MT 59604-5805
Questions? Call (406) 444-6900
Make checks payable to the Department or Revenue
x
Extension Tax Payment only
1. Year Ending Date
/
/
-
-
2. Social Security Number
,
.
,
3. Amount Paid
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