Form 0405-668 - Alaskaapplication For Extension Of Time To File The Mining License Tax Return

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Alaska
668
This application must be filed no
later than the due date of the return.
Application for Extension of Time to File
the Mining License Tax Return
NOTE: Approval of this application does NOT extend the time to pay any tax due.
EIN
Name of Individual or Firm
Daytime Telephone Number
SSN
Mailing Address
City
State
Zip Code
Period of time for which the extension is requested:
For the calendar year
or beginning
fiscal year
,
month
year
ending
,
month
year
Please check type of request:
The person making this application on behalf of the named
business is:
Extension of time to file for License Tax on Mines and Mining
The owner or partner
I wish to renew my mining license(s) for license year
An officer of the corporation
An agent for the business
Please explain the reason an extension of time to file is needed
Under penalty of unsworn falsification, I declare that to the best of my knowledge and belief, this application is true, correct and complete.
Signature
Date
DEPARTMENT USE ONLY
Approved
Denied
Date Extension Will End
Explanation
dor.tax.mining@alaska.gov
668
Mail to: Alaska Department of Revenue, PO Box 110420, Juneau AK 99811-0420
0405-668 Rev 09/12

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