Application For Tax Status Report - New York City Department Of Finance
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1FOR OFFICE USE ONLY
NEW YORK CITY DEPARTMENT OF FINANCE
COLLECTIONS DIVISION
: ___________
APPLICATION FOR
DATE RECEIVED
TM
: _____________
TAX STATUS REPORT
TSA NUMBER
Department of Finance
: _______________
AUDITOR
Mail to: NYC Dept. of Finance, Collections Division, Tax Status, 59 Maiden Lane, 24th Floor, New York, NY 10038
Instructions: Please complete and sign this application before mailing to the address above. See below for further details.
SECTION I - APPLICANT’S INFORMATION
Applicant's
Taxpayer’s
Name:_________________________________________________________ Email Address:______________________________
PRINT FIRST NAME
PRINT LAST NAME
Applicant's
Address:__________________________________________________________________________________________________
/
NUMBER AND STREET
APT
STE
City
Zip
Country
Telephone
and State:_____________________________ Code:___________ (if not US):__________ Number:_______________________
Name of
Employer
Subject Corporation:_______________________________________________ Identification Number_______________________
Subject
Corporation's Address:_______________________________________________________________________________________
/
NUMBER AND STREET
APT
STE
City
Zip
Country
Telephone
and State:_____________________________ Code:___________ (if not US):__________ Number:_______________________
State or County
Date of
Date Business
of Incorporation:________________________ Incorporation: _______/_______/______ Began (in NYC): _______/_______/_______
SECTION II - CERTIFICATION
I certify that the statements made herein have been examined by me and are, to the best of my knowledge and belief, true, correct and complete.
Please sign and date:
DATE
__________________________________________________________________________
____________ ____________ ____________
Signature
q
q
RELATIONSHIP TO
REPRESENTATIVE
OFFICER
CORPORATION (Check one):
(see instructions)
INSTRUCTIONS FOR TAX STATUS REPORT
All Sections of this application must be completed in its entirety.
Power of Attorney:
Submit a fully-executed Power of Attorney form with the application. This must be submitted by any authorized rep-
resentative of the subject corporation requesting the tax status report. Incomplete applications will not be accepted.
Mailing Address:
Mail this completed application and completed Power of Attorney form (if applicable) to:
NYC Department of Finance
Collections Division, Tax Status
59 Maiden Lane, 24th Floor
New York, NY 10038
If you have any questions, call Tax Status at (212) 908-7623 or (212) 908-7010.
Tax Status Application 2017
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