Department of Taxation and Finance
TR-371
PrompTax – Withholding Tax Statement of
(8/15)
Exemption from Mandatory Participation
Taxpayer ID number
Taxpayer name
Taxpayer street address
City
State
ZIP code
Primary contact name
Primary contact email address
Primary contact phone number
Primary contact fax number
Department records indicate that you may be required to participate in the PrompTax withholding tax program. Review
the exemption criteria listed below. If you qualify for either of the exemptions, you must complete and submit this form to
establish that you are not required to participate.
Check the box next to each exemption criterion that applies to you:
Health Care Providers that are organizations described in Public Health Law Article 28 or 36 or in Mental Hygiene
Law Article 16 or 31 are exempt from participation in the program. You must attach a copy of the operating certificate
issued by the Department of Health.
The aggregate tax withheld on Form NYS-45, Quarterly Combined Withholding, Wage Reporting, and Unemployment
Insurance Return, for all four quarters of the tax year immediately prior to the year for which you are requesting
exemption, is less than $100,000. You must attach copies of Form NYS-45 for all four quarters related to the tax year
immediately prior to the year for which you are requesting exemption.
You will receive notification granting or denying your exemption request within 14 days.
Mail this form to:
NYS TAX DEPARTMENT, PROMPTAX WITHHOLDING TAX, W A HARRIMAN CAMPUS, ALBANY NY 12227-0865
See Publication 55, Designated Private Delivery Services, if not using U.S. Mail.
Questions?
•
Visit our Web site at
•
Call the PrompTax Customer Service Center at (518) 457-2332
This form requires a notarization.
Signature of chief fiscal officer:
Printed name of signatory:
Date:
Signature of notary public
Date
Notary public: affix stamp (or other indication of notary’s authority).
Keep a copy of this completed form for your records.
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