Request For Cigarette Tax Installment Agreement Form
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1NYC DEPARTMENT OF FINANCE
ENFORCEMENT DIVISION
R E Q U E S T F O R
F I N A N C E
C I G A R E T T E T A X I N S T A L L M E N T A G R E E M E N T
NEW YORK
THE CITY OF NEW YORK
DEPARTMENT OF FINANCE
Mail to: NYC Department of Finance, Enforcement Division, 345 Adams Street, 13th Floor, Brooklyn, NY 11201
Instructions: Please complete this form in its entirety and return to the address above with-
in ten (10) business days. You must include an initial payment of not less than 25% of your
total liability.
If your request is denied: We will notify you in writing and the outstanding balance will be due
immediately. If your request is approved: You will be allowed to satisfy your outstanding lia-
bility in monthly installments as you have indicated below. Generally, you can have up to 60
months to pay.
Since you will not be receiving any additional correspondence or bills from this office con-
cerning this liability, you will be responsible for ensuring that payments are made each month
until the outstanding balance is paid in full. Failure to make payments under the agreement
may lead to collection measures, including the imposition of penalties.
:
:
:
CIGARETTE TAX TRACKING NUMBER
SOCIAL SECURITY NUMBER
DOF USE ONLY
(
)
SEE YOUR TAX PAYMENT FORM
:
:
:
PRINT FIRST NAME
PRINT LAST NAME
DAYTIME PHONE NUMBER
#
:
:
:
:
STREET
AND ADDRESS
CITY
STATE
ZIP CODE
TOTAL AMOUNT
NUMER OF MONTHLY
AMOUNT OF EACH
ANTICIPATED
:
:
:
:
OF TAX DUE
PAYMENTS REQUESTED
MONTHLY PAYMENT
COMPLETION DATE
$
$
(
):
REASON FOR REQUEST
EXPLAIN THE NATURE OF YOUR FINANCIAL HARDSHIP
:
:
’
SIGNATURE
TODAY
S DATE
Visit Finance at nyc.gov/finance
CigTaxInstallAgm- 09/14/06
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