Request For Relief - Storm Sandy (2012)
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REQUEST FOR RELIEF – STORM SANDY (2012)
General Instructions: This form is to be completed by those Connecticut taxpayers who were affected by
Storm Sandy. Taxpayers who, as a direct result of the storm and related flooding, are unable to comply with
Connecticut tax payment and/or filing obligations may be eligible for relief from penalty and interest that
resulted from their noncompliance. If you believe that you are eligible for relief, please complete this form and
send it to:
Department of Revenue Services
Attention: Storm Sandy Relief
PO Box 2997
Hartford, Connecticut 06106-2997
Taxpayers may also fax this form to the Department at 860-297-4797. This form must be signed by the
taxpayer or, in the case of corporations, partnerships, limited liability companies, estates and trusts, by a
person authorized to execute returns or pay tax on behalf of the taxpayer. For additional information, please
contact the Department at (860) 297-4771.
Part 1 – Taxpayer Information
Taxpayer’s name
Social Security Number or
Connecticut Tax Registration Number
Spouse’s Name (If Joint Liability)
Spouse’s Social Security Number
Mailing address
City, State, and Zip Code
Physical Address (Number and Street) (If Different
City, State, and Zip Code
From Above)
Daytime telephone number
For DRS Use Only Case ID Number
(
)
Part 2 – Request for Relief: Please complete the appropriate section below.
A. Individuals
1. Please identify the specific tax type (e.g., income tax) and period for which you are seeking relief:
Tax type:______________________________
Tax period:_____________________________
2. Please identify the due date of the return or payment and the date you actually filed said return or made
said payment:
Due Date or Payment Date:_________________
Date filed or paid:________________________
3. Please check the appropriate box:
I/We are seeking relief from:
□
Penalty and/or interest that is/are currently due.
□
Penalty and/or interest that I/we have already paid.
4. Please complete the following:
I/We __________________________________________ certify that:
(write name(s))
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