Form M-4768a - Application For Extension Of Time To Pay Massachusetts Estate Tax
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1
2Rev. 10/99
Form M-4768A
Massachusetts
Application for Extension of Time to Pay
Department of
Massachusetts Estate Tax
Revenue
File in duplicate with payment.
Name of decedent
¨
Mail to:
Probate court
Date of death
¨
Name of
¨
applicant
Docket number
Decedent’s Social Security number
¨
Street address
Residence (domicile) at time of death
City/Town,
State, Zip code
Part 1. Extension of Time to Pay
Application is hereby made to the Commissioner of Revenue for the following extension of time to pay the Massachusetts Estate T ax on the estate
named above.
Extension of time to pay
Based solely on reasonable cause
Based solely on undue hardship.
Mass. estate tax return due date
Based on undue hardship with alternate request for reasonable cause if undue hardship is denied.
Reason extension is applied for:
Extension date requested
¨
Part 2. Payment to Accompany Extension Request
¨
1. Estimated amount of Massachusetts estate tax due . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
2. Less: Advance and/or estimated payments made (if any) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
3. Prior extension payments (attach copy of Form M-4768 and/or Form M-4768A) . . . . . . . . . . . . . . . . . . . . . . .
$
4. Balance due with this application. Subtract the total of line 2 and line 3 from line 1 . . . . . . . . . . . . . . . . . . . . .
$
Part 3. Certification
Name of executor, administrator, or person in possession of decedent’s property
Name of attorney for estate
Street address
Street address
City/Town
State
Zip
City/Town
State
Zip
I declare under the penalties of perjury that this application has been examined by me and to the best of my knowledge and belief it is true
and correct.
Signature
Title
Date
Signature
Title
Date
Part 4. Notice to Applicant.
To be completed by Estate Tax Bureau.
The application for extension of time to pay is:
Approved
Not approved
Other.
Commissioner of Revenue
Date
By
Make check payable to the Commonwealth of Massachusetts. Send to: Massachusetts Department of Revenue, Estate Tax Bureau, PO Box 7023,
Boston, MA 02204. Attach a copy of this application to the Estate Tax Return when filed.
Form code: 653
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