Form 3855 - Michigan Tax Amnesty Application - 2011
Download a blank fillable Form 3855 - Michigan Tax Amnesty Application - 2011 in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form 3855 - Michigan Tax Amnesty Application - 2011 with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2Reset Form
Michigan Department of Treasury
Michigan Tax Amnesty
3855 (Rev. 03-11)
Ends June 30, 2011
Michigan Tax Amnesty Application
Issued under authority of Public Act 198 of 2010. Filing is voluntary.
Amnesty will not be granted if this form is not filed. See instructions on Page 2.
PART 1: TAXPAYER IDENTIFICATION (Type or Print)
1. Taxpayer Name (Last, First, Middle Initial)
2. Taxpayer’s Social Security Number
FOR
INDIVIDUALS
3. Spouse’s Name (Last, First, Middle Initial)
4. Spouse’s Social Security Number
ONLY
State
ZIP Code
5. Mailing Address (No., Street, P.O. Box)
City
7. Federal Employer Identification Number (FEIN)
6. Business Name (DBA)
FOR
BUSINESSES
8. Business Contact Person
9. Business Title
10. State Where Incorporated
ONLY
11. Mailing Address (No., Street, P.O. Box)
City
State
ZIP Code
PART 2: TAX PAYMENT DETAIL
If additional space is needed, refer to Michigan Tax Amnesty Supplemental Schedule (Form 3874).
E
H
D
F
A
B
C
G
Amount of
Taxable Period
Amount of
Total Tax and
Tax Type
Assessment
Tax Due
(MM/YYYY)
Interest Due
Interest Due
Code
Number
(X)
(C)
12.
13.
14.
15.
16.
17.
18.
19.
19. Enter total of Column G. ................................................................................................ SUBTOTAL.
20.
Check here if you have continued Part 2 on the Supplemental Schedule (Form 3874)
20.
and enter the Schedule total here. ........................................................................................
21.
21. TOTAL. Add lines 19 and 20. .......................................................................... PAY THIS AMOUNT.
22.
22. PAYMENT. ....................................................................... TOTAL AMOUNT PAID WITH THIS FORM.
23.
Check here if you have included a tax return that claims a refund with this amnesty application.
PART 3: CERTIFICATION
I declare under penalty of perjury that I am eligible for amnesty under the conditions listed on page 2 of this form and that the information on this form
and any accompanying returns and schedules is, to the best of my knowledge, true, correct and complete.
Date
Taxpayer Telephone Number
Signature of Taxpayer or Authorized Business Official
Taxpayer’s Spouse’s Signature
Date
Tax Preparer’s Telephone Number
I authorize Treasury to discuss this application with my Tax Preparer.
Tax Preparer’s Name
Yes
No
Mail the Amnesty application with returns and payment to: Michigan Department of Treasury, Tax Amnesty,
P.O. Box 30710, Lansing, MI 48909. For additional information, visit or call toll-free (855) 466-4829.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial