Form M-911 - Taxpayer'S Application For Relief Due To Hardship (Page 2 of 2) in pdf

Form M-911 Instructions

When to Use This Form

8. Tax years or periods. If you are requesting assistance on an

annually filed return, enter the calendar year or the ending date of

Use this form to apply for relief from a significant hardship which

the fiscal year for that return. If the problem concerns a return filed

may have already occurred or is about to occur if the Department

quarterly or monthly, enter the ending date of the quarter or month

of Revenue (DOR) takes or fails to take certain actions. A signifi-

involved. File only one Form M-911 even if multiple tax periods are

cant hardship means not being able to provide the necessities of

at issue. If the problem involves more than one tax period, include

life for you or your family. Examples of such necessities include, but

the information in line 10.

are not limited to: food, shelter, clothing, or medical care.

9. Tax type. Check the tax type for which you are requesting

If you have not tried to obtain relief from the DOR office that most

assistance. For example, if your problem involves a personal in-

recently contacted you, use of this form may not be necessary. For

come tax form, check “personal income tax,” or enter the tax type

example, employees from both the Customer Service Bureau and

in the space provided. If your problem involves more than one tax

the Collections Bureau can handle requests for payment agree-

type, include the information in line 10.

ments on late taxes or release of a levy on wages, salaries or bank

accounts. The Collections Bureau handles past due liabilities equal

10. Description of significant hardship. Describe the action being

to or greater than $5,000. Customer Service employees handle re-

taken, or not being taken, by DOR that is causing you significant

quests for refunds of overpaid taxes and liabilities less than $5,000.

hardship. If you know it, include the name of the person, office, tele-

Audit employees can address penalty waiver requests when an ad-

phone number, and/or address of the last contact you had with DOR

ditional tax assessment is being made.

regarding this problem.

Note: Do not use this application to request a change in the amount

11. Description of relief requested and supporting documen-

of tax you owe. If you disagree with the amount of tax assessed,

tation. Be specific. Describe what action you would like DOR to

you must file an Application for Abatement (Form CA-6) within the

take. Along with the signed Form M-911, you must include a list of

time allowed for making an application. To obtain a Form CA-6 or if

monthly income and expenses, any debit statements from a bank

you have questions about a bill that you don’t understand, please

or financial institution showing any levied amounts, and your most

call the Customer Service Bureau at (617) 887-MDOR, or toll-free

recent income voucher (e.g., pay stub or pension statement). If

in Massachusetts at 1-800-392-6089.

there are missing tax returns for the last three years and there was

no requirement to file, include a signed statement to this effect. Also

Where to Submit This Form

include copies of any documents that you believe will substantiate

the hardship claim.

Mail this application to Massachusetts Department of Revenue,

Office of the Taxpayer Advocate, PO Box 9552, Boston, MA

12 and 13. Signature(s). If you filed a joint return it is not neces-

02114-9552, or fax to (617) 626-3799.

sary for both you and your spouse to sign this application for your

account to be reviewed. If the taxpayer is your dependent child

Caution: Incomplete applications or applications submitted

who cannot sign this application because of age, or someone in-

to the incorrect office may result in delays. If you do not hear

capable of signing the application because of some other reason,

from DOR within seven days of submitting Form M-911, please

you may sign the taxpayer’s name in the space provided followed

contact the Office of the Taxpayer Advocate at (617) 626-2280.

by the words “By (your signature), parent (or guardian).” If the ap-

plication is being made by other than the individual taxpayer, a per-

Taxpayer Information

son having authority to sign the return should sign this form. Enter

1. Name as shown on tax form. Enter your name as it appeared

the date Form M-911 is signed.

on the tax return for each period from which you are asking for re-

Submission of this document may require DOR to request your sig-

lief, even if your name has changed since the return was submitted.

nature agreeing to suspend applicable statutory period(s) of limita-

5. Mailing address (number and street). If your post office does

tions for the assessment and/or collection of additional tax.

not deliver mail to your street address and you have a PO box,

enter your box number instead of your street address.

Power of Attorney

6. Telephone number. Enter the daytime telephone number, in-

If you wish to have a representative act on your behalf, you must

cluding area code, of the person whom DOR should contact, either

assign to that representative power of attorney for the tax type(s)

the taxpayer or the Power of Attorney.

and period(s) involved. To do so, complete the Power of Attorney

section on page 1 of Form M-911, or file Form M-2848.

7. Federal Identification number. If you are requesting considera-

tion of hardship relief from a business tax liability, enter the Federal

Identification number (FID) of the business, corporation, trust, es-

tate, etc., for the name shown in line 1.

Form M-911 - Taxpayer'S Application For Relief Due To Hardship Page 2

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