Form Ar1055 - Request For Extension Of Time For Filing Income Tax Returns, Vouchers Ar1000es And Ar1100esct - 2004 Page 3

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AR1100ESCT
State of Arkansas
5
FOR OFFICE USE ONLY
2004 Corporation Income Tax
Extension Payment Voucher
Tax Year Ending __________________________
Payment included with extension request must be
reported on this voucher.
MONTH/YEAR
_______________________________________________________
FEIN
Amount of this payment:
$
.00
____________________________________________
Return this Voucher with check or money order payable to:
NAME OF CORPORATION
Department of Finance and Administration
____________________________________________
MAIL TO: Corporation Income Tax Section
ADDRESS - NUMBER AND STREET
P. O. Box 919
Little Rock, Arkansas 72203-0919
____________________________________________
CITY, STATE AND ZIP CODE

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