Form 6750 - Alaska Application For Voluntary Disclosure - 2013

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Alaska Application For Voluntary Disclosure
Part I
Representative’s Name
State Agency
Department of Revenue - Tax Division
Representative’s Mailing Address
Mailing Address
550 W. 7th Ave. Ste. 500
City, State, Zip Code
City, State, Zip Code
Anchorage, AK 99501-3555
Representative’s Email Address
Questions? Email
Representative’s Telephone Number
Representative’s Fax
Telephone Number
Fax Number
Part II
Tax Periods:
Entity Type:
1. Has the entity ever filed an income tax return with the
Department of Revenue?
S Corporation
2. Has the entity ever been the subject of an inquiry by
the Department of Revenue with respect to liability for
LLC (Limited Liability Company)
income taxes?
Part III
Attach the following information to the application:
• A description of the qualified business entity’s business activities
• A description of the qualified business entity’s business in Alaska
• The facts giving rise to the offer to enter into a Voluntary Disclosure Agreement
• Whether the DOR has contacted the entity, and if so, the nature of such contacts
• The settlement terms proposed by the company
• If the entity is a partnership or LLC, the number of corporate partners or members
• A statement with your estimate of the amount of taxes due by tax period. Show the accompanying computations.
Part IV
I declare under penalty of perjury under the laws of the State of Alaska, that I am authorized by the unnamed entity to act as its agent in negotiating
a settlement under Alaska’s Voluntary Disclosure Program and that the information in this application, including accompanying schedules and
statements, is true and correct to the best of my knowledge and belief.
Person Completing Form (Print Name)
0405-6750 Rev 01/01/14
6750:01 01 14


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