Application For Extension Of Filing Time / Prepayment Of Individual Income Tax - Tennessee Department Of Revenue

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TENNESSEE DEPARTMENT OF REVENUE
APPLICATION FOR EXTENSION OF FILING TIME / PREPAYMENT OF INDIVIDUAL INCOME TAX
Beginning
ACCOUNT NUMBER
YOUR SSN:
INC
Taxable
Year
Ending
251
SPOUSE'S SSN:
FEIN:
(If filing jointly, include the first names, middle initials, and last names of both spouses.)
The statutory due date of the return is the
______________________________________________________________________
Name:
fifteenth day of the fourth month commencing
after the end of the taxpayer's year. Make your
Spouse's Name:
______________________________________________________________
check payable to the Tennessee Department
of Revenue for the amount on Line 4 and mail to:
____________________________________________________________________
Address:
Tennessee Department of Revenue
________
____________
State:
City:
Zip:
_______________________________________
Andrew Jackson State Office Bldg.
500 Deaderick Street
Nashville, TN 37242
Should you need assistance, please contact the
Taxpayer and Vehicle Services Division by calling
Please provide the county and city (if within an incorporated municipality) of the taxpayer's legal
our statewide number 1-800-342-1003 or (615)
residence for this filing period on the lines below:
253-0600. You may file your extension through
County: ____________________________________________________________
the Internet at
City: _______________________________________________________________
APPLICATION FOR EXTENSION OF FILING TIME: Check the box to the left to apply for a six-month extension of filing time to file the Indi-
vidual Income Tax Return. If an estimated payment is made with this request, complete Lines 1 through 4 below. An extension shall be
granted provided that either this form or a copy of the taxpayer's federal extension request is attached to the return filed on or before the
extended due date. Interest will accrue on unpaid tax from the original due date of the return until the date paid. No penalty will accrue with
a valid extension. If the return is not filed with payment of the tax due by the extended due date, penalty will accrue as though no extension
had been granted.
PREPAYMENT OF TAX: Check the box to the left if using this form to make a prepayment of individual income tax for the taxable year
shown above. Enter the amount of the payment on Line 4 below.
CHECK THE APPLICABLE BOX:
Married Filing Separately
Limited Liability
Estate
Single
Married Filing Jointly
Trust
(enter spouse's SSN # above also)
Partnership
Company
WRITE NUMBERS LIKE THIS
ROUND TO THE NEAREST DOLLAR
COMPUTATION OF ESTIMATED TAX/PREPAYMENT
1. TOTAL TAXABLE INCOME (Dividend income plus interest income)................................................................(1)
00
$1,250 if single or married filing separately
{
00
2. SUBTRACT EXEMPTION
..........................................(2)
$2,500 if married filing jointly
00
(3)
3. AMOUNT SUBJECT TO TAX (Line 1 less Line 2).........................................................
4. ESTIMATED TAX/PREPAYMENT (6% of Line 3)...........................................................
(4)
00
Under penalties of perjury, I declare that I have examined this request and, to the best of my knowledge and belief, it is true, correct, and complete.
FOR OFFICE
Taxpayer's Signature
Spouse's Signature
Date
USE ONLY
(
)
Tax Preparer's Signature
Date
Telephone
Preparer's Address
City
State
Zip
INTERNET (11-07)
RV-R0003601

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