Form Fae 173 - Application For Extension Of Time To File Franchise, Excise Tax Return - 2015
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1TENNESSEE DEPARTMENT OF REVENUE
APPLICATION FOR EXTENSION OF TIME TO FILE
RV-R0011401
INTERNET (8-15)
FRANCHISE, EXCISE TAX RETURN
Account No.
Taxable Year
FEIN
FAE
Beginning:
173
Due Date
Ending:
Make your check payable to the Tennessee
Department of Revenue for the amount shown on
Line 4 of the worksheet and mail to:
TAXPAYER NAME AND MAILING ADDRESS
NAME ___________________________________________________________________
Tennessee Department of Revenue
Andrew Jackson State Office Bldg.
BOX (STREET) ____________________________________________________________
500 Deaderick Street
Nashville, TN 37242
CITY ____________________________________________________________________
STATE ________________
ZIP __________________________
An extension of time of six (6) months will be granted, provided you meet the requirements outlined on the reverse side of the form.
REMINDERS
1)
Enter account number or FEIN in the spaces provided.
2)
Quarterly estimated tax payments made for the year, available tax credits, and overpayments from prior years should be deducted
when computing the payment due.
3)
If previous year's credit(s) and current year's estimated tax payment exceed estimated liability, enter 0 on Line 4.
4)
Sign and date your return in the signature box below.
5)
See reverse side for additional procedures for obtaining an extension of time.
ROUND TO NEAREST DOLLAR
WORKSHEET FOR COMPUTATION OF EXTENSION PAYMENT
00
1. Estimated Franchise Tax current year .....................................................................................................................
___________________________
00
2. Estimated Excise Tax current year ............................................................................................................................
___________________________
00
3. Deduct: Prior year's overpayment, estimated payments and tax credits for current year ..........................................
___________________________
00
4. Amount due with extension request (Lines 1 and 2 less Line 3) ................................................................................
___________________________
WRITE NUMBERS LIKE THIS
Keep Upper Portion For Your Records
Return Copy Below - Detach Here
TENNESSEE DEPARTMENT OF REVENUE
File this form only if a payment is being made. If your account number is not preprinted or
FAE
Application for Extension of Time to File Franchise, Excise Tax
unknown, enter federal identification number/social security number.
173
Extended
Filing
Due Date
Period
(FEIN/
SSN)
ACCOUNT
AMOUNT DUE
00
(Line 4 of
worksheet)
Under penalties of perjury, I declare that I have examined this report, and to the best
of my knowledge and belief, it is true, correct, and complete.
FOR OFFICE USE ONLY
________________________________________
_________
______________
Taxpayer's Signature
Date
Title
________________________________________
_________
______________
Tax Preparer's Signature
Date
Telephone
________________________________
____________
_________
_______
Preparer's Address
City
State
ZIP
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