Form M-911 - Taxpayer'S Application For Relief Due To Hardship

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Form M-911
Massachusetts
Taxpayer’s Application
Department of
for Relief Due to Hardship
Revenue
If you are sending Form M-911 with another form or letter, put Form M-911 on top. Please use this form only after reading the instructions. Filing
this application may affect the statutory period(s) of limitations for the assessment and/or collection of additional tax.
Taxpayer Information
11 Name of taxpayer, as shown on tax form
2 Taxpayer’s Social Security number
13 Name of spouse
4 Spouse’s Social Security number
15 Mailing address
City/Town
State
Zip
16 Telephone number of taxpayer or attorney-in-fact (include area code)
7 Federal Identification number (if a business)
18 Tax year(s) or period(s)
9 Tax type (check one):
Personal income tax
Other
10 Description of significant hardship. Use additional paper, if necessary.
11 Description of relief requested. Include supporting documentation. Use additional paper, if necessary.
12 Signature of taxpayer or appropriate officer. See instructions.
Date
13 Signature of spouse
Date
Power of Attorney
The taxpayer shown on this application appoints the following individual(s) as attorney(s)-in-fact to represent the taxpayer(s) before the Department of
Revenue for the above-named tax matter(s) and any subsequent periods for the same types of tax through the date of this notice. The attorney-in-fact is
authorized, subject to limitations set forth on this form, to receive confidential information and to perform any and all acts that the principal(s) can perform
with respect to the above-specified tax matters, excluding the power to receive refund checks.
Signature of taxpayer
Date
Signature of spouse
Date
Signature of attorney-in-fact
Title
Name of firm
PTIN or SSN
Date
Mailing address
City/Town
State
Zip

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