Form 355-7004 Misc. - Application For Extension Of Time To File Financial Institution, Insurance Or Miscellaneous - 2012

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Form 355-7004 Misc.
2012
Application for Extension of
Massachusetts
Time to File Financial Institution,
Department of
Insurance or Miscellaneous
Revenue
This application may be filed by corporations filing Form 63FI, 63-20P, 63-23P, 121A, P.S.1 or 63-29A. All other business/manufacturing corpora-
tions that file Forms 355, 355S, 355U, 355SC or SBC Corporation Excise Returns must file Form 355-7004 when applying for an extension of
time to file.
Application for Extension
Name of corporation
Federal Identification number
For tax year beginning
Ending
Street address
City/Town
State
Zip
Return to be filed:
Financial institutions
Insurance
Public utility
Urban redevelopment
Ocean marine
Type of extension being applied for:
a. Automatic six-month extension
b. Extension until:
Reason for extension:
Tentative Return
1 Estimated amount of tax for the taxable year (must be at least minimum tax) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2 Advance and/or estimated payments made (if any). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
3 Tax due with this application. Subtract line 2 from line 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Payment in full of the tax due must be made with this application for it to be considered valid. If at least 50% of the tax due or the minimum tax (whichever
is greater) for the taxable year is not paid, the extension is null and void. Penalties for a late return will be assessed from the original due date of the return.
Declaration
I declare under the penalties of perjury that I have been authorized by the above-named corporation to make this application and that to the
best of my knowledge and belief the statements made herein are true and correct.
Signature of officer or agent
Title
Date
Signature of paid preparer
Address
Date
Mail to: Massachusetts Department of Revenue, PO Box 7052, Boston, MA 02204.

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