Form M-4868 - Application For Automatic Six-Month Extension

PRINT IN BLACK INK

Ovals must be filled in completely. Example:

For the year January 1–December 31, 2003 or other taxable year beginning

, 2003, ending

Form M-4868

Application for Automatic Six-Month Extension

2003

File your extension by telephone. See instructions.

Part 1. Application for Automatic Six-Month Extension of Time to File Massachusetts Income Tax Return

YOUR SOCIAL SECURITY NUMBER

FIRST NAME

M.I.

LAST NAME

–

SPOUSE’S SOCIAL SECURITY NUMBER

SPOUSE’S FIRST NAME

M.I.

LAST NAME

–

ADDRESS

CITY/TOWN/POST OFFICE

STATE

ZIP + 4

Type of return filed (select one):

Form 1

Form 1-NR/PY

Telefile

Total tax you expect to owe for 2003 (see Form 1, lines 27 and 33 (if applicable); Form 1-NR/PY,

lines 31 and 38 (if applicable); Telefile Worksheet, line 12) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Massachusetts income tax withheld . . . . . . . . . . . . . . . . . . . . . 2

2002 overpayment applied to your 2003 estimated tax

(do not enter 2002 refund) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

2003 Massachusetts estimated tax payments (do not

include amount in line 3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Credits (see Form 1, lines 30, 38 and 39; Form 1-NR/PY,

lines 35, 43 and 44). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Total. Add lines 2 through 5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Tax due. Subtract line 6 from line 1; not less than “0.” Pay in full with this application. . . . . . . . . . . . . . . ❿ 7

Note: You should file this application by touch-tone telephone. See reverse for more information.

Confirmation number

Part 2. Complete if Prepared by Someone Other than Taxpayer

If prepared by someone other than taxpayer, this application must be submitted on paper.

I am authorized to prepare this application and I am (select one):

a member in good standing of the bar of the highest court of (specify jurisdiction)

a certified public accountant, or public accountant, duly qualified to practice in (specify jurisdiction)

a person enrolled to practice before the Internal Revenue Service

a duly authorized agent holding a power of attorney with respect to filing an extension of time (the power of attorney need not be submitted

unless requested)

a person standing in close personal or business relationship to the taxpayer who is unable to sign this application because of illness, absence, or

other good cause; my relationship to the taxpayer and the reasons why the taxpayer is unable to sign this application are

Write your Social Security number(s) on lower left corner of check. Make check payable to Commonwealth of Massachusetts and mail to:

Massachusetts Department of Revenue, PO Box 7070, Boston, MA 02204.

SIGN HERE. Under penalties of perjury, I declare that to the best of my knowledge and belief this return and enclosures are true, correct and complete.

Your signature

Your daytime phone

Date

Paid preparer’s signature

Preparer’s SSN or PTIN

–

(

)

Spouse’s signature (if filing jointly)

Spouse’s daytime phone

Date

Employer Identification number