Form Apl-004 - Deposit In The Nature Of A Cash Bond - Connecticut Department Of Revenue Services

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State of Connecticut
Department of Revenue Services
FORM APL-004
Appellate Division
25 Sigourney Street
Deposit in the Nature of a Cash Bond
Hartford, CT 06106-5032
(Rev. 7/99)
Read the instructions on the reverse side before completing this form. Complete Form APL-004 if you have protested an assessment
or are planning to file a protest with the Appellate Division and you want to make a deposit to stop the accrual of interest. The benefit
of completing this form is that your deposit is applied first to any outstanding tax due and then interest due, under Conn. Gen. Stat.
§12-39m(b), based on the ratio calculated below.
This form must be signed by:
• A principal officer, if the taxpayer is a corporation
• The fiduciary, if the taxpayer is a trust or an estate
• A partner, if the taxpayer is a partnership
• An individual or sole proprietor, if the taxpayer is an
• A principal officer, if the taxpayer is an LLC
individual or sole proprietorship
• The general partner, if the taxpayer is an LLP
1. Taxpayer’s Name
5. CT Tax Registration Number or Social Security Number
2. Address (Number and Street)
6. Federal Employer Identification Number (Business Only)
3. City, State and ZIP Code
7. Tax Type Audited
4. Revenue Examiner Conducting Audit Examination:
8. Tax Periods Involved in the Audit Examination
9. Taxpayer is:
Corporation
Partnership
Estate
Sole Proprietorship
Trust
Individual
Other ________________
10. Tax billed (Attach a copy of billing notice OAR 140)
10.
11. Total interest accrued through date of deposit
11
(See Instructions on reverse side)
12. Total (Add Line 10 and Line 11)
12.
13. Ratio (Divide Line 10 by Line 12.
13.
Carry the result 4 decimal places)
14. Amount deposited with this form
14.
15. Deposit applied to final tax due (Multiply Line 13 by Line 14)
15.
16. Deposit applied to final interest due
16.
(Subtract Line 15 from Line 14)
If you need help in completing this form, please call 860-297-4775, Monday through Friday, 8:00 am and 5:00 pm.
Signature
Title
Date
Print Your Name
Print Company Name

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