Application For Tax Status Report - New York Department Of Finance

FOR OFFICE USE ONLY

NEW YORK CITY DEPARTMENT OF FINANCE

COLLECTIONS DIVISION

: ___________

DATE RECEIVED

A A P P P P L L I I C C A A T T I I O O N N

F F O O R R

: _____________

TSA NUMBER

T T A A X X S S T T A A T T U U S S R R E E P P O O R R T T

Finance

: _______________

AUDITOR

Mail to: NYC Dept. of Finance, Collections Division, Tax Status, 59 Maiden Lane, 28th Floor, New York, NY 10038

Instructions: Please complete and sign this application before mailing to the address above. See below for further details.

SECTION I - APPLICANT’S INFORMATION

Applicant's

Taxpayerʼs

Name:_________________________________________________________ Email Address: ______________________________

PRINT FIRST NAME

PRINT LAST NAME

Applicant's

Address: __________________________________________________________________________________________________

NUMBER AND STREET

APT

STE

Zip

Telephone

City: _________________________________ State: _____________ Code: ____________ Number: _______________________

Name of Subject Corporation: _________________________________________________________________________________

Subject Corporation's Address: ________________________________________________________________________________

NUMBER AND STREET

APT

STE

Zip

City: _________________________________ State: _____________ Code: ____________ EIN:___________________________

State or County

Date of

Date Business

of Incorporation: ________________________ Incorporation: _______/_______/______ Began (in NYC): _______/_______/_______

SECTION II - CERTIFICATION

I certify that the statements made herein have been examined by me and are, to the best of my knowledge and belief, true, correct and complete.

Please sign and date:

DATE

__________________________________________________________________________

____________

Signature

RELATIONSHIP TO

REPRESENTATIVE

OFFICER

CORPORATION (Check one):

(see instructions)

INSTRUCTIONS FOR TAX STATUS REPORT

All Sections of this application must be completed in its entirety.

Fees:

There is a $5.00 processing fee. Please make check or money order to the New York City Department of Finance

and mail to the address below. This processing fee is non-refundable.

Power of Attorney:

Submit a fully-executed Power of Attorney form with the application. This must be submitted by any authorized rep-

resentative of the subject corporation requesting the tax status report. Incomplete applications will not be accepted.

Mailing Address:

Mail this completed application, the $5.00 processing fee and completed Power of Attorney form (if applicable) to:

NYC Department of Finance

Collections Division, Tax Status

59 Maiden Lane, 28th Floor

New York, NY 10038

If you have any questions, call Tax Status at (212) 232-1828.

Tax Status Application 2013

Application For Tax Status Report - New York Department Of Finance - 2013

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