Form Ar1055 - Request For Extension Of Time For Filing Income Tax Returns, Vouchers Ar1000es And Ar1100esct - 2004 Page 2

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PAYMENT WITH EXTENSION
5
State of Arkansas
Voucher for Individuals
Individual Income Tax
P. O. Box 9941
AR1000ES
Little Rock, AR 72203-9941
Fiscal Year Ending:
Month
Day
Year
Spouse’s Social Security Number (If joint return)
Your Social Security Number
20 ____
Tax Year
First Name and Initial (If joint, use first names and initials of both)
Last Name(s)
Amount of this
Address (Number and street, apartment number or rural route)
Installment
$
City, State and Zip Code
5
CLICK HERE TO CLEAR FORM

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