Us Department Of Justice Tax Check Waiver Page 2

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MY NAM E:______________________________________________
MY SSN:_________________________
(Please print or type)
CURREN T ADD RESS:_________________________________________________________________________
TELEPH ONE N UM BERS: (HOME ) _________________________ (WORK) ___________________________
(Please include area code s)
IF MARRIED AND FILED A JOINT RETURN:
SPOUSE'S NAME :________________________________________
SPOUSE'S SSN: _____________________
NAMES AND ADDRESSES SHOWN ON RETURNS (IF DIFFERENT FROM ABOVE)
YEAR
N AM E
ADDRE SS
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
1. Answer yes or no: In the last seven years, have you failed to file a federal or state tax return?
Yes
No If yes, please exp lain why in the space provided below. (Attach additional pages, if necessary.)
2. Answer yes or no: During the last seven tax years, did yo u file a federal or state tax return m ore tha n 45 days
after the due date for filing? Include any tax returns due more than seven years ago that were not filed until
sometime d uring the last seven years (e.g., a tax return due eight years ago that was not filed until five years a go).
Yes
No
If yes, please explain why in the space provided b elow. (Attach additional pages, if necessary.)
3. Answer yes or no: During the last seven tax years, did yo u mak e a federal or state tax p ayment more than 45 d ays
after notice and demand? Include any tax payments due more than seven years ago that were not pa id in full until
sometime during the last seven years, as well as tax payments made pursuant to installment agreements with the IRS
or state tax authority.
Yes
No
If yes, please exp lain why in the space provided below. (Attach additional pages, if necessary.)
4. Answer if applicable; if not applicable, indicate “N/A”: If there was insufficient income to meet filing
requirements, or filing requirements were m et by filing with a foreign tax agency (e.g., Puerto Rico or the V irgin
Islands), please describe the circumstances in the space pro vided below. (Attac h add itional pages, if necessary.)
Explanation(s) and further information:_____________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
DATE:_______________________________ Signature:______________________________________
(WAIVER INVALID UNLESS
(Signature of Taxpayer Authorizing
RECEIVED BY THE IRS
the Disclosure of Return Information)
WITHIN 60 DAYS OF THIS DATE)
DOJ-488
(Rev. 4/00)

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